Sports Medicine Fellowship Application

General Information

Applicant Name:*

Date of Birth:*

National Provider Identification (NPI):*

Anticipated Fellowship Start Date:*

Current Address:*

Telephone Number:*

( ) -

Email Address:*

Alternate Email Address:

Birthplace:*

Citizenship:*

Immigration Status or Visa type:

Major Hobbies, Interests, Skills:*

Clinical/Research Interests in Pediatric Sports Medicine:*

Emergency Contact

Emergency Contact Name:*

Emergency Contact Phone Number:*

( ) -

Emergency Contact Email Address:*

Undergraduate

Undergraduate College/University:*

Undergraduate Degree(s), Major(s):*

Undergraduate Dates of Enrollment:*

Medical School

Medical School:*

Medical School Dates of Enrollment:*

Medical School Degree(s):*

Other Graduate Education

Other Graduate School(s):

Other Graduate Degree(s):

Residency

Pediatric Residency Institution:*

Pediatric Residency Dates:*

Residency Program Director:*

Department Chairman:*

References

Reference Contact Information:*

Please include the names, title/affiliation, and contact information for three (3) individuals providing letters of reference.

One letter of reference should be from the applicant’s most recent program director. Letters of reference may be submitted directly via email to Dr. James Toldi at jtoldi1@jhmi.edu and Rita Priore at rpriore2@jhmi.edu, or via standard mail to:
Division of Pediatric Sports Medicine
Johns Hopkins All Children's Hospital
600 5th Street South, 4th floor
St. Petersburg, Florida 33701

Personal Records

Have you ever been convicted of a felony?:

Have you ever been dismissed from a professional or educational position?:

Has your license or ability to practice medicine ever been suspended or revoked?:

Has your DEA number or ability to prescribe narcotics ever been rescinded?:

Has any medical organization ever subjected you to disciplinary actions?:

Additional Documentation:

If you responded "Yes" to any Personal Records questions above, please provide written explanation in a separate document

Supporting Information

Personal statement:*

Please describe why you have decided to pursue fellowship training in Pediatric Sports Medicine. Include your future professional aspirations and limit the separate Word document to 300 words or less.

Curriculum vitae (CV):*

Please provide a copy of your current CV.

Student Evaluation:*

Please provide a Dean’s Letter or Medical Student Performance Evaluation (MSPE)

Medical school transcript:*

Exam Scores:*

Please provide your PG-year, USMLE scores (Step 1, 2 CK and CS, and 3), COMLEX scores (Level 1, 2 CE and PE, and 3), or MCCQE scores (Exams 1 and 2).

ECFMG certificate number (if applicable):

Recent photo (optional):

Sports Medicine Fellowship Application

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External Links

General Information

Emergency Contact

Undergraduate

Medical School

Other Graduate Education

Residency

References

Personal Records

Supporting Information

Sports Medicine Fellowship Application

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Related Pages

External Links

General Information

Emergency Contact

Undergraduate

Medical School

Other Graduate Education

Residency

References

Personal Records

Supporting Information