JPS Health Network | Treating Your Family With Care
Application for Clinical Clerkship Form
Clinical Clerkship Desired:

1st Choice: From:
2nd Choice: From:
3rd Choice: From:

Current Address:
City, State, ZIP:
Current Phone:
Home Address:
City, State, ZIP:
Home Phone:
* Email address must be supplied for response to inquiry.

Pre-Med (Pre-Dental) College or University:
Medical (Dental) School:
Name of Faculty Sponsor:
Name of Professional Liability Company:
*Please have the school forward a letter regarding liability coverage

Classification as of July 1 of current year: Junior   Senior
Social Security Number:
Do you Plan to Apply for JPSH
Post-Graduate Training?
Yes   No   Undecided
   If YES, list speciality or internship 
Do you Plan a Residency NOT Offered at JPSH? Yes   No   Undecided
  If YES, list speciality or internship 
How Did You Hear About The Programs at JPSH?
Why Do You Want a JPSH Clerkship?
* Please have the school send a letter indicating that you are a student in good standing.


Forward all materials to:

Margie Behringer, Medical Student Coordinator
Physicians Services Department
John Peter Smith Hospital
1500 South Main Street
Fort Worth, TX 76104