Application for Trainee

Personal Information

The University of Texas Health Science Center at Tyler (UT Health Northeast) would like to extend a warm welcome to all visitors and students interested in an educational experience on our campus. In order to do so there are required processes in place to assure we have accurate information on the students and also to carry out the Mission, Vision, and Values of the institution. Please carefully read the instructions below and throughout the form to assist you with the accurate completion of this application.

You must consent to a background check or provide an attestation from your school.
Family Medicine Clerkship students should contact Megan McLaughlin (Megan.McLaughlin@uthct.edu) for the appropriate attestation form.
Once your application is approved and rotation dates have been determined, all students will be required to complete an institutional orientation at UT Health Northeast. During orientation you will receive pertinent information regarding UT Health Northeast, its policies, non-disclosure forms, HIPAA confidentiality, etc.
At this time the University of Texas Health Science Center at Tyler is not authorized to sponsor F1 visas. J1 and H1b visas require a working/employee status which is not applicable to the non-research based visitor types explained in the categories above.

1. Full Legal Name: *This question is required.

2. Phone

3. Email:

4. Date of Birth:

5. Hometown:

6. Address:

7. Emergency Contact:

8. Emergency Contact Phone: