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CMMC Family Practice Residency Program Registration Form
Please fill out the following registration form to be considered for the program.
Cell Phone Number
Home Mailing Address
Major/s (if declared)
Your Class Year
First Year (Class of 2021)
Sophomore (Class of 2020)
Junior (Class of 2019)
Senior (Class of 2018)
Check which semesters you will be on campus.
Short Term 2018
Which parts of the Bates/CMMC Partnership do you wish to participate in this semester?
Didactic lectures (open to anyone)
Shadowing at the Family Practice Residency's Family Medicine Clinic (open to Sophomores, Juniors and Seniors) Note: HIPPA training and proof of immunizations required.
Shadowing interns and residents on CMMC's Family Medicine Inpatient Floor (open to Juniors and Seniors with significant healthcare experience) Note: HIPPA training and proof of immunizations required.
Do you have proof of the following immunizations? (Measles, Mumps, Rubella, Hepatitis B, Varicella, Negative PPD (results within the past 12 months), and Flu Vaccine (during appropriate time of year)
Have you been through HIPPA training through CMMC?
Have you spoken with Karen Daigler or Lee Abrahamsen about this opportunity?
What experience(s), if any, have you had working in a health care setting?
List 3 goals that you hope to achieve through this opportunity.