Family Medicine Elective Request Form Family Medicine Elective Request Form Name* First Last BU Email Address* In what specialty or specialties are you planning to apply:* If applying in Family Medicine, do you have a field-specific advisor (FSA)?* If Yes, who is your FSA?* What block is your Sub-I and which specialty is it in?* Please rank the elective or electives you are interested in and indicate the top 3 blocks you prefer for eachBlock 9: 05/29/23-06/25/23--- Block 10: 06/26/23-07/23/23--- Block 11: 07/24/23-08/20/23--- Block 12: 08/21/23-09/17/23--- Block 13: 09/18/23-10/15/23--- Block 14: 10/16/23-11/12/23--- Block 15: 11/13/23-12/10/23--- Block 16: 12/11/23-01/14/24--- Block 17: 01/15/24-02/11/24--- Block 18: 02/12/24-03/10/24--- Block 19: 03/11/24-04/07/24--- Block 20: 04/08/24-05/05/24Please click on the plus sign to add another field to add additional blocks (max 3) Please identify which elective is your preferred elective (For example, if you ranked the same block for two electives, identify which elective you prefer)*Sports Medicine (Blocks 12,13,14,15,17,18, and 19)Maternal Child Health (Blocks 9,10,12,13,14,15,16,17,18,19, and 20)Student Health Services (Blocks 13 and 19)Family Medicine 360 BMC (Block 11)Family Medicine Boot Camp (Block 19B) Please click on the plus sign to add another field to add additional blocks (max 3) Please identify which elective is your preferred elective (For example, if you ranked the same block for two electives, identify which elective you prefer)