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FACULTY OF HEALTH SCIENCES

FM Horizontal Elective

Name *

First

Last

Email *

Preceptor Name *

Preceptor Email *

Rotation Information

This form has 5 date entry lines. If you require more than 5, you need to complete an additional form

Requested Rotation Date *

Requested Rotation Date

Requested Rotation Date

Requested Rotation Date

Requested Rotation Date

Location of prearranged rotation *

Burlington Clinical Education Campus - Joseph Brant
Grand Erie Six Nations Clinical Education Campus - Brantford, Paris, Dunnville, Simcoe, Hagersville, Caledonia, Delhi, Oshweken, Port Dover
Halton Clinical Education Campus - Georgetown/Halton Hills, Milton, Oakville
Niagara Regional Campus - Fort Erie, Niagara Falls, Port Colborne, St. Catharines, Welland, Grimsby, Beamsville, Niagara-on-the-Lake, Smithville
Osler Clinical Education Campus - Brampton, Etobicoke, Peel Memorial Centre for Integrated Health & Wellness
Waterloo Regional Campus - Cambridge, Guelph, Fergus, Mount Forest, Palmerston, Kitchener, Drayton, Elmira, Elora, Rockwood, Waterloo, Wellesley
OTHER

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