RPMS DOSE!

RPMS DOSE Program
Students

Name:
Email Address:		College:
Phone:		Year:
Do you have a car, and would you be willing to drive to a DOSE location?	Yes No
Have you ever taken part in a doctor shadowing program or volunteered for a doctor's office/clinic? Elaborate. (Please include any similar experience):
Why do you want to volunteer for a DOSE physician?
Any preference for a specialty?
What other activities and time commitments will you be involved in this semester? How many hours per week will you have available to commit as a DOSE participant?

Please include the times which you are available to shadow
Monday	Tuesday	Wednesday	Thursday	Friday	Saturday	Sunday

Note: we cannot guarantee a shadowing experience in your preferred field, but any information would greatly help us.
Also, please keep in mind that most physicians are available during the weekdays rather than weekends.
Having hours available during the weekday may facilitate the matching process. Thank you.