[cpvc_custom_form_container cpvc_select_campaign=”9″ cpvc_success_msg=”Thanks, we’ll be in touch shortly!” cpvc_failure_msg=”Please enter a valid email address.” cpvc_label_visibility=”1″][cpvc_textfield field_label=”Name” field_name=”FNAME” required_field=”1″][cpvc_emailfield field_label=”Email” required_field=”1″][cpvc_textfield field_label=”I’m a medical student at” field_name=”School” placeholder=”Your current university” required_field=”1″][cpvc_dropdown field_label=”I’m interested in a” field_name=”Duration” dd_options=”1 month clerkship
3 month clerkship” required_field=”1″][cpvc_dropdown field_label=”I’m interested in programs located in” field_name=”Country” dd_options=”United States
Turkey” required_field=”1″][cpvc_textarea field_label=”What disciplines are you most interested in?” field_name=”Disciplines” required_field=”1″]
Examples: Ambulatory Care, Cardiology, Clinical Pathology, Community Medicine, Dermatology, Emergency Medicine, Family Medicine, Gross Anatomy, Infectious Diseases, Internal Medicine, Obstetrics & Gynecology, Ophthalmology, Orthopedic Anatomy, Orthopedic Surgery, Otorhinolaryngology, Pediatrics, Public Health, General Surgery