STUDENT ACCEPTANCE FORM

Electives Application for Students Registered at Canadian/American Medical Schools
Faculty of Medicine
3655 Promenade Sir William Osler
Montreal, QC H3G 1Y6
Canada
Fax: (514) 398-3595
Faculté de médecine
3655 Promenade Sir William Osler
Montréal (QC) H3G 1Y6
Canada
Télécopieur: (514) 398-3595
STUDENT ACCEPTANCE FORM
I,
, residing at
in the
city of
wishing to gain practical experience in (discipline) _________________________at
McGill University in the Faculty of Medicine, and in consideration of the training that I will receive as a result of the agreement
between McGill and its affiliated host institution ("Institution"), and the home university, hereby agree to the terms and conditions
below:
I will undertake such functions and responsibilities consistent with the student training program approved by McGill and its
Institution, and which McGill may specify from time to time.
1.
I understand that as a student of McGill, I remain subject to the rules, regulations and policies of McGill, including but not
limited to, those contained in the Charter of Student Rights and Responsibilities
http://www.mcgill.ca/files/secretariat/Handbook-on-Student-Rights-and-Responsibilities-2010.pdf.
2.
I will carry sufficient personal accident and health insurance. My home university will provide liability insurance, which
includes contingent medical malpractice coverage. If not covered by my university, this has been indicated by my home
institution, and I understand that I am eligible only for electives at the MUHC hospital sites (Montreal General Hospital,
Royal Victoria Hospital, Montreal Children’s Hospital, Montreal Chest Institute and Montreal Neurological Institute).
3.
I shall keep confidential all information shared with me during the work experience by the Institution.
4.
I shall acquaint myself with the policies and procedures of the Institution as well as the safety requirements to perform my
tasks.
5.
I will be responsible for all my expenses, and I hereby declare that I am financially capable of meeting such expenses
incurred on my behalf.
6.
I will not cause McGill and its Institution to incur any expense, including but not limited to: telephone, telecommunications,
and transportation, and I will promptly and fully reimburse McGill and its Institution for any expenses.
7.
I will not engage in any occupation or trade, whether paid or unpaid, while on the work experience.
8.
I hold McGill and its Institution harmless from any claims, demands or actions of any kind, and shall indemnify McGill and its
Institution from any loss or expenses incurred, and accept full responsibility for my participation in the work experience.
9.
I understand that should I violate McGill's or its Institution's policies or procedures, or demonstrate unprofessional or
unethical conduct, or not be able to perform my duties at the level expected of me, McGill or its Institution may terminate my
work experience.
10. If accepted for an elective, I authorize McGill University to forward the letter of acceptance to the Collège des médecins du
Québec. (This item not applicable to students at Quebec medical schools.)
11. I understand that it is my responsibility to provide my Collège des médecins du Québec registration number to my
supervisor/hospital department so that they can bill the Régie d'Assurance Maladie (RAMQ) for teaching activities.
12. I have requested that the present document be drafted in the English language. J'ai demandé que le présent document soit
rédigé dans la langue anglaise.
Signed:
Date: