Wisconsin Academy of Family Physicians
Passport Program
Application Form
Name:
Address:
City, State, Zip:
Phone:
Email address:
Medical School:
Check programs you are intending to visit:
Baraboo Rural Training Track
Columbia/St. Mary’s FMRP
Eau Claire FMRP
Fox Valley FMRP
LaCrosse-Mayo FMRP
Madison FMRP
Mercy Health System FMRP
Racine FMRP
St. Luke's FMRP
St. Joseph FMRP
Waukesha FMRP
Wausau FMRP
Please return this form by using the "Submit" button,
or copying and pasting in an email to
amy@wafp.org
,
or printing and faxing to WAFP at 262-242-1862
or mailing to WAFP, 210 Green Bay Road, Thiensville, WI 53092.
You will be notified of your eligibility for reimbursement of travel expenses within two weeks.