Practice-Based Ambulatory Program
and Veterinary Preceptorship
Department of Large Animal Clinical Sciences
Student Profile
Name: Student #:
Maiden Name (if applicable):
Street Address: Phone:
City/State ZIP:
Email Address: Current Date:
IN CASE OF EMERGENCY, PLEASE NOTIFY:
Name: Relationship (i.e., parent, spouse):
Phone:
1. Please provide a brief personal background with emphasis on your food animal and equine experience. (Select all that apply.)
I have limited food animal experience.
I have moderate to extensive food animal experience (please expand on this below).
I have limited equine experience.
I have moderate to extensive equine experience (please expand on this below).
Additional Comments:
2. The Practice-Based Ambulatory Program includes many mixed-species practices. If given a choice, which of the following
species mixes would you prefer for your practice-based ambulatory experience?
mixed equine/food animal and small animal
mixed equine and food animal
a practice that is exclusively equine or food animal
3. Is there any particular area in the state where housing would be provided to you at no cost during your clerkship(s)?
Yes No If yes, where?
Please note: This does not guarantee your being placed in this area.
With the exception of the comments below this line, a copy of this profile will be sent to the practice(s) to which you are assigned.
Questions answered below the line are for in-house use only and will be omitted from the copy sent to the practice(s).
4. List any large animal practices in Michigan where you have previously spent time observing or working.
5. List any special conditions that should be considered during placement for your practice-based ambulatory clerkship(s). (Health
conditions, family obligations, smoking preference, etc.)
FS03