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Application - Learner
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Position Type
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Dietician/Nutritionist
Medical Student/Clerk
Medical Resident
Midwife
Nurse Practitioner
Observer
Physical Therapy
Physician Assistant
Psychologist
Residency Program
-- Select Residency Program --
Anesthesiology
Biochemestry
Cardiac Surgery
Cardiology
Clinical Immunology aand Allergy
Colorectal Surgery
Critical Care (ICU)
Dermatology
Diagnostic Radiology
Emergency Medicine
Endocrinology
Family Medicine
Family Medicine (Anesthesia)
Family Medicine (Emergency Medicine)
Family Medicine (Enhanced Skills)
Family Medicine (Sport and Exercise)
Gastro-Enterology
General Surgery
Genetics
Geriatric Medicine
Health & Preventive Medicine
Hematology
Hospitalist Medicine
Infectious Diseases
Internal Medicine
Medical Microbiology
Medical Oncology
Nephrology
Neurology
Nuclear Medicine
Obstetrics and Gynecology
Ophthalmology
Orthopedic Surgery
Other
Otolaryngology
Palliative Medicine
Pathology
Pediatrics
Physical Medicine and Rehabilitation
Plastic Surgery
Psychiatry
Radiation Oncology
Respirology
Rheumatology
Surgical Oncology
Thoracic Surgery
Unassigned
Urology
Vascular Surgery
Stream
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Select Stream
Rural Stream
Urban Stream
FMTU – Markham
FMTU – Barrie
FMTU – Newmarket
FMTU – Peterborough
Program
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Romp
Romp - AHP
Romp - Internation Learner
Personal Information
First Name
Last Name
Gender
Male
Female
N/A
Use of Car
-- Select Use of car --
No
Yes
Home Town
Phone Number
Street
Postal Code
City
Email
School Information
Current University
-- Select Current University --
Department of Defence
McMaster University
Northern Ontario School of Medicine
Other
Out of Country
Out of Province
Queen's University
University of Ottawa
University of Toronto
University of Western Ontario
Out of Province University
-- Select Current University --
Dalhousie University
McGill University
Memorial University of Newfoundland
Universitè de Montrèal
Universitè de Sherbrookè
Universitè Laval
University of Alberta
University of Calgary
University of Manitoba
University of Saskatchewan
Unversity of British Columbia
Date of MD
Other University
Student Number
CPSO Number
Year Of School
-- Select Year Of School --
1
2
3
4
5
6
7
8
Clerk
CMPA Number
Medical University
-- Select Medical University --
Department of Defence
McMaster University
Northern Ontario School of Medicine
Other
Out of Country
Out of Province
Queen's University
University of Ottawa
University of Toronto
University of Western Ontario
Out of Province Medical University
-- Select Medical University --
Dalhousie University
McGill University
Memorial University of Newfoundland
Universitè de Montrèal
Universitè de Sherbrookè
Universitè Laval
University of Alberta
University of Calgary
University of Manitoba
University of Saskatchewan
Unversity of British Columbia
Year of Residency Completion
Rotation Information
From Date
To Date
Number of Weeks
Rotation Type
-- Select Rotation Type --
Core
Elective
Hire a med - CSJ
Summer Elective
Summer Student
Preceptor, if known
Rotation Discipline
-- Select Rotation Discipline --
Anaesthesiology
Cardiac Surgery
Cardiology
Clinical Immunology and Allergy
Colorectal Surgery
Critical Care (CCU) Medicine
Critical Care (ICU) Medicine
Dermatology
Diagnostic Radiology
Emergency Medicine
Endocrinology and Metabolism
Family Medicine
Family Medicine (Anes)
Family Medicine (EM)
Gastro-Enterology
General Surgery
General Surgery Oncology
Geriatric Medicine
Hematology
Hospitalist (FM)
Hospitalist (IM)
Infectious Disease
Internal Medicine (General)
Medical Genetics
Medical Oncology
Nephrology
Neurology
Nuclear Medicine
Obstetrics and Gynecology
Ophthalmology
Orthopaedic Surgery
Other
Otolaryngology
Paediatrics
Palliative Medicine
Pathology
Physical Medicine and Rehabilitation
Plastic Surgery
Psychiatry
Public Health and Preventive Medicine
Radiation Oncology
Respirology
Rheumatology
Sports Medicine
Thoracic Surgery
Urology
Vascular Surgery
Community Requests
Community Requests Unavailable During Rural Medicine Week
First Choice
-- Select First Choice --
Barrie
Brant County (Ayr, Brantford, Paris, St George, Waterford)
Cambridge
Centre Wellington (Elora, Fergus)
Chelsey
City of Kawartha Lakes (Bobcaygeon, Fenelon Falls, Lindsay, Woodville)
Clarington Township (Bowmanville, Newcastle)
Collingwood-Creemore-Stayner-Wasaga Beach
Durham
Erin
Exeter
Fort Erie
Georgina-Keswick-Sutton
Guelph
Haldimand County (Caledonia, Cayuga, Dunnville, Hagarsville, Haldimand)
Haliburton
Halton Hills (Georgetown, Limehouse)
Hanover
Innisfil
Kincardine
Kinmount-Minden
Kitchener-Waterloo
Lions Head
Listowel
Markdale
Markham-Stouffville
Meaford
Midland-Penetanguishene
Milton
Minden
Minto-Mapleton (Drayton, Palmerston)
New Tecumseth (Alliston, Beeton, Tottenham)
Niagara Falls
Niagara on the Lake
Norfolk County (Delhi, Jarvis, Port Dover, Simcoe)
Northumberland (Cobourg, Port Hope)
Norwich
Orangeville (Shelburne)
Orillia
Other (M)
Other (N)
Owen Sound
Peterborough
Port Colborne
Port Elgin
Port Perry
Rousseau/Wahta
Seaforth
South Hampton
St Catharines
Thorold
Tillsonburg
Town of the Blue Mountains (Clarksburg, Thornbury)
Trent Hills (Campbellford, Hastings, Warkworth)
Uxbridge
Walkerton
Waterdown
Welland
Wellington North (Arthur, Mount Forest)
West Lincoln (Beamsville, Grimsby, Smithville)
Wiarton
Wingham
See Profile
Accommodations Required
Yes
No
Connections To Community
Yes
No
Second Choice
-- Select Second Choice --
Barrie
Brant County (Ayr, Brantford, Paris, St George, Waterford)
Cambridge
Centre Wellington (Elora, Fergus)
Chelsey
City of Kawartha Lakes (Bobcaygeon, Fenelon Falls, Lindsay, Woodville)
Clarington Township (Bowmanville, Newcastle)
Collingwood-Creemore-Stayner-Wasaga Beach
Durham
Erin
Exeter
Fort Erie
Georgina-Keswick-Sutton
Guelph
Haldimand County (Caledonia, Cayuga, Dunnville, Hagarsville, Haldimand)
Haliburton
Halton Hills (Georgetown, Limehouse)
Hanover
Innisfil
Kincardine
Kinmount-Minden
Kitchener-Waterloo
Lions Head
Listowel
Markdale
Markham-Stouffville
Meaford
Midland-Penetanguishene
Milton
Minden
Minto-Mapleton (Drayton, Palmerston)
New Tecumseth (Alliston, Beeton, Tottenham)
Niagara Falls
Niagara on the Lake
Norfolk County (Delhi, Jarvis, Port Dover, Simcoe)
Northumberland (Cobourg, Port Hope)
Norwich
Orangeville (Shelburne)
Orillia
Other (M)
Other (N)
Owen Sound
Peterborough
Port Colborne
Port Elgin
Port Perry
Rousseau/Wahta
Seaforth
South Hampton
St Catharines
Thorold
Tillsonburg
Town of the Blue Mountains (Clarksburg, Thornbury)
Trent Hills (Campbellford, Hastings, Warkworth)
Uxbridge
Walkerton
Waterdown
Welland
Wellington North (Arthur, Mount Forest)
West Lincoln (Beamsville, Grimsby, Smithville)
Wiarton
Wingham
See Profile
Accommodations Required
Yes
No
Connections To Community
Yes
No
Third Choice
-- Select Third Choice --
Barrie
Brant County (Ayr, Brantford, Paris, St George, Waterford)
Cambridge
Centre Wellington (Elora, Fergus)
Chelsey
City of Kawartha Lakes (Bobcaygeon, Fenelon Falls, Lindsay, Woodville)
Clarington Township (Bowmanville, Newcastle)
Collingwood-Creemore-Stayner-Wasaga Beach
Durham
Erin
Exeter
Fort Erie
Georgina-Keswick-Sutton
Guelph
Haldimand County (Caledonia, Cayuga, Dunnville, Hagarsville, Haldimand)
Haliburton
Halton Hills (Georgetown, Limehouse)
Hanover
Innisfil
Kincardine
Kinmount-Minden
Kitchener-Waterloo
Lions Head
Listowel
Markdale
Markham-Stouffville
Meaford
Midland-Penetanguishene
Milton
Minden
Minto-Mapleton (Drayton, Palmerston)
New Tecumseth (Alliston, Beeton, Tottenham)
Niagara Falls
Niagara on the Lake
Norfolk County (Delhi, Jarvis, Port Dover, Simcoe)
Northumberland (Cobourg, Port Hope)
Norwich
Orangeville (Shelburne)
Orillia
Other (M)
Other (N)
Owen Sound
Peterborough
Port Colborne
Port Elgin
Port Perry
Rousseau/Wahta
Seaforth
South Hampton
St Catharines
Thorold
Tillsonburg
Town of the Blue Mountains (Clarksburg, Thornbury)
Trent Hills (Campbellford, Hastings, Warkworth)
Uxbridge
Walkerton
Waterdown
Welland
Wellington North (Arthur, Mount Forest)
West Lincoln (Beamsville, Grimsby, Smithville)
Wiarton
Wingham
See Profile
Accommodations Required
Yes
No
Connections To Community
Yes
No
I Give Permission to select another community location if my choices are unavailable.
Expectations of Learning Experience
Please clearly indicate any educational expectations (clinic, hospital or other) to ensure that you are matched with a preceptor who meets your learning objectives. Please also note any additional details regarding community placement, or accommodation requests in the notes section below.
Program Coordinator Notes
Please add your program coordinator information and pertinent contact details.
Name of Program Director
By submitting this application, I agree to abide by all of the policies (available at http://romponline.com/wp-content/uploads/2014/09/ROMP-PreceptorLearnerPolicyManual2011.pdf) and confirm that I have not applied to any other rural placement programs. I understand that once the ROMP coordinator has contacted me with the name of a preceptor, it is unprofessional for me to cancel the rotation. I acknowledge that ROMP will notify my school of any unprofessional behaviour.
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Learner Travel Amount
Learner Cheq. Ref.
Learner Accom Amount
Learner Accom Cheq. Ref.
Invoice Sent
Preceptor Invoice Sent Date
Administration Notes
Accommodation Name :
Accommodation Type :
Payment Amount :
ROMP Pays Directly
Accommodation Booking Notes
Community Notes
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