RAJIV GANDHI UNIVERSITY OF SCIENCE AND TECHNOLOGY

Clinical Rotation

Student Name & Address:

Last Name

First Name

Middle / Initial

Student ID

House No.

Street

City

State/Province

Zip Code/Postal Code

Country

Tel No.

Cell No.

E-mail

In order to schedule clinical rotations, the form needs to be submitted at least six (06) weeks prior to the requested start date. Students are required to have this document completed and submitted to the Clinical Rotation Coordinator of Greenheart Medical University, School of Medicine for clearance from the Bursar & Registrar’s Departments.

Rotation (s) Requested

No. of Weeks

Start Date

Core / Elective

Additional Comments:

Have you any medical condition or learning disability that may require special attention during medical school?

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