Bates College Experiential Learning Program with the CMMC Family Practice Residency Program

Name*
First Last
Student ID*
Bates E-mail*
Cell Phone*
Home Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Major/s (if declared)
Class Year (e.g. "2026")*
Are you on Financial Aid at Bates College?*
Will you need assistance to pay for the background check?*
Which semesters will you be on campus and able to participate in the program?
Which parts of the Bates/CMMC Partnership do you wish to participate in this semester?*
- a) Didactic lectures (open to anyone)
- b) Shadowing at the Family Practice Residency's Family Medicine Clinic (open to Sophomores, Juniors and Seniors)
- c) Shadowing interns and residents on CMMC's Family Medicine Inpatient Floor (open to Juniors and Seniors with significant healthcare experience)
For b and c above you will need to provide proof of the following immunizations: Measles, Mumps, Rubella, Hepatitis B, Varicella, COVID, Flu (during appropriate time of year), negative PPD results within the past 12 months, and a TB test, all filed with Bates Health Services. Participants will also need titers for Measles, Mumps, Rubella, Hepatitis B, and Varicella, all of which can be obtained through Bates Health Services. Please contact Kathy Morin (MorinKa@cmhc.org) from Bates Health Services for assistance, and to obtain your immunization and titers records, which you will then forward to James Smith (jsmith6@bates.edu).
Have you been through HIPPA training?*
- Yes
- No
If you have been through HIPPA training, how/where did you complete the training?
Have you completed a background check through Corporate Intelligence?*
- Yes
- No
Have you spoken with Bruno Salazar-Perea or Lea Staedtler at the Bates Center for Purposeful Work about this opportunity?*
- Yes
- No
What experience(s), if any, have you had working in a health care setting?
List 3 goals that you hope to achieve through this opportunity
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