Registration for the clinical clerkship

Title*

First name*

Surname*

E-Mail*

Phone number

University/ Medical School*

Degree Program*

Current Year/ Semester*

Student ID Number

Preferred period (from-to)

Mandatory Internship

Yes

Preferred Department*

Department of Neonatology, Pediatric Intensive Care and Neuropediatrics - IMC

Department of Neonatology, Pediatric Intensive Care and Neuropediatrics - NICU

Department of Neonatology, Pediatric Intensive Care and Neuropediatrics - PICU

Department of Neonatology, Pediatric Intensive Care and Neuropediatrics - Neuro-oncology

Department of Pediatric Pulmonology, Allergology and Endocrinology - Ward

Department of Pediatric Pulmonology, Allergology and Endocrinology- General Outpatient Clinic

Department of Pediatric Cardiology - Ward

Department of Pediatric Nephrology and Gastroenterology - Ward

No preference (placement based on availability)

Are alternative dates possible?*

Yes

If you selected ‘Yes’ in the field above, please provide specific details below.

Alternative periods (from – to)

Previous clinical internships*

Yes

If yes: please specify institution(s)

Special skills / interests

German*

Englisch*

Additional languages

Curriculum Vitae*

Motivation letter

Certificate of Enrollment*

How did you hear about us?

Additional comments

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