Veterinary Externship Application

Name *

First

Last

Email *

Phone Number *

Address *

Date of Birth *

Perferred Method of Communication *

• Phone
• Email

Best Time to Call

Current School *

Year of Expected Graduation *

Contact Information for 4th Year Advisor or Director of Student Services *

How did you hear about our program? *

What dates are you interested in coming to GVEC? *

Do you require housing? (veterinary externs ONLY) *

• Yes
• No

Which High School did you attend? *

What school did you attend for Undergraduate studies? *

Please list any other educational experiences you would like to include.

What is your past experience with horses? *

What are your specific veterinary interests? *

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.

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