DI Elective Request Form

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Name:

Today's Date:

Elective Requested:

Preceptor:

Preceptor confirmed availability.

Yes

If your elective is out of Calgary please complete the following:

City of Hospital:

Travelling with family?

Yes

If your elective is within Alberta or the North West Territories the DRLI group can help with accommodations.

Block Number

Objectives of Elective:

Objectives of Elective:
	Objectives of Elective:	Item weight

more items

Collection of personal information
Your personal information is collected under the authority of section 33(c) of the Freedom of Information and Protection of Privacy Act. If you have any questions about the collection or use of this information, please visit our Access to Information page.