Genesee Valley Equine Clinic | Pre-Veterinary Externship Application

Pre-Veterinary Externship Application

This form is for undergraduate students pursuing post-graduate education in veterinary school.

Name *

First

Last

Email *

Phone Number *

Address *

Date of Birth *

Perferred Method of Communication *

Phone
Email

Current Undergraduate School *

Current Level of Study *

How did you hear about our program? *

What Dates or Days of the week are you interested in coming to GVEC? *

Are you applying for:

Summer program
School Year program
Both Summer and School Year

Which High School did you attend? *

Any other educational experiences you would like to list?

What is your past experience with horses? *

Have you ever ridden with an ambulatory veterinarian? *

Insurance Coverage - Medical Insurance Company: *

Students must carry their own medical insurance while at GVEC

Insurance Coverage - Subscriber Name *

Insurance Coverage - Telephone Number *

Insurance Coverage - Policy Number *

Emergency Contact #1 *

First

Last

Emergency Contact #1 Address *

Street, City, State, Zip Code

Emergency Contact #1 Phone *

Emergency Contact #2

First

Last

Emergency Contact #2 Address

Street, City, State, Zip Code

Emergency Contact #2 Phone

Genesee Valley Equine Clinic Confidentiality Agreement. *

By checking this box, I acknowledge that I have read the confidentiality policy and agree to abide by it.

The medical records of the horses that are treated by Genesee Valley Equine Clinic are strictly confidential. We treat our doctor/client/patient relationships with our highest respect, and for legal and professional reasons, we do not discuss the diagnosis, treatment, prognosis or any other aspect of our cases with anyone other than the owner of the horse.As a student, employee or assistant at Genesee Valley Equine Clinic we ask that you maintain this confidentiality. You should not discuss any medical information with anyone outside of the clinic, even on a casual basis. If pressed on this issue, you may simply reply that you have signed a confidentiality agreement and are not able to speak about business at the clinic.Our business depends on the trust of our clients. Thank you for honoring our confidentiality policy.

How would you describe your relationship to animals? How has this affected your decision to pursue a career as a veterinarian? *

Tell us about your extracurricular activities (hobbies, 4-H, volunteer work, etc.) and describe how they have shaped you. *

What is the most challenging job you have held, and why? *

Upon submission of this application, you will be prompted to provide two letters of reference from teachers, employers, or organization leaders. Please list the two names we will be expecting letters from. *

First

Last

Reference #1

First

Last

Reference #2

Pre-Veterinary Externship Application

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