Medical College of Wisconsin Clinical Apprenticeship Sign Up Form

Discovery Curriculum Teaching Toolbox

Thank you for your interest in the Clinical Apprenticeship and Preceptor program in the Discovery Curriculum at the Medical College of Wisconsin. Please complete this form to add your name to our database for future student assignments. Any questions about the program, contact Dana Sibilski (dsibilski@mcw.edu) or (414) 955-8196.

Physician Information

First Name

Last Name

Title

Employer

Specialty

I am an existing faculty or volunteer faculty at MCW Yes No

Contact Information

Physician Email *

Physician Phone

Physician Pager

Assistant Name

Assistant Email

Assistant Phone

Facility Information

Hospital or Clinic

Address where student would report

City

Availability

In order to participate in the Early Clinical Experiences Clinical Apprenticeship program, physicians would be required to host a student for four hours on either Monday afternoon, Tuesday afternoon, Thursday morning or Friday afternoon.

Monday afternoon Tuesday afternoon Thursday morning Friday afternoon

Let us know if you have questions or have any additional information to include