Application for the MEDICAL STUDENTS CLINICAL ELECTIVE - CAM

Transcription

1 Application for the MEDICAL STUDENTS CLINICAL ELECTIVE - CAM MEDICAL EDUCATION COOPERATION With CUBA Dates of Elective you are applying for: Send a p p lic a tion ma teria ls a nd the a p p rop ria te a p p lic a tion fee to: Passport Information Please print clearly 1. Please read passport carefully while completing this section. Complete name and dates as appear on passport. Last Name First Name Middle Name (if on passport) 2. Gender: O Male O Female 3. Birth date: 4. Place of birth: Month / Day / Year State/province, country 5. Passport Number: 6. Date of issue: Month / Day / Year 7. Place of issue: 8. Date of expiration: Month / Day / Year Personal Information 9. Address Please provide your complete address, making sure to clearly indicate capital letters and numbers. 10. Current Mailing Address City State Zip Code / 11. Home Telephone Number / Daytime Telephone Number 12. Permanent Mailing Address (if different from current address) 13. Ethnic Status: Choose one that best describes you. Your response is voluntary, and will help us assess diversity in. O Black or African American O Hispanic or Latino O Native American/Alaska Native O Asian/Pacific Islander O White/Caucasian O other EMERGENCY CONTACT INFORMATION Contact Name: Phone(s): Relation to you: Address:

2 Education & Training 14. I am currently enrolled in: O Mph Program (year) Please print clearly O other 15. Name of School 16. School Mailing Address 17. Additional Training: Institution Location Degree/Date received 18. List any special awards, honors or fellowships you have received 19. List memberships in professional and social service organizations Experience 20. List experience in developing countries (other than vacation time) 21. List local/community service 22. List other pertinent experience Professional Interests 23. List possible areas of specialization in the future Spanish Proficiency Note: All classroom and fieldwork is conducted in Spanish. 24. Please indicate your level of Spanish: Advanced/Fluent = can easily converse in Spanish, translate, read, and write the language. Intermediate = can converse in Spanish, with some reading and writing skills. Letters of Recommendation 25. List the names of the individuals that will write your recommendation letters. One must be a faculty member at your school. Name Title Relationship Address Day Phone address if available Name Title Relationship Address

3 Day Phone Medical Information address if available Please print clearly 26. Are you currently taking any prescription medications? yes no 27. Do you have any special dietary needs? yes no If yes, please specify: 28. Do you have any allergies to food or medicine? yes no If yes, please specify: 29. Are you currently under the care of a physician for a chronic medical condition? yes no If yes, please specify: Signature 30. I certify that all the information in this application is true and accurate. I understand that withholding information or making false statements will disqualify me from participating in the program. Applicant signature Date Essay Requirement 31. Please answer both (A) and (B). (A) Why are you qualified to be a participant in the Program? Please discuss any prior experience you feel may be appropriate as well as your personal motivation. (Limit 300 words) (B) How do you see your participation in as a contribution to your career development? Describe the professional path you plan to take after graduation. (Limit 300 words) Check List Do you have all of these items? 1. Completed application form (including essays) TWO COPIES 2. Signed and dated Participant Agreement TWO COPIES 3. Completed Academic Credit Certificate (to be completed by appropriate university office) TWO COPIES 4. Photocopy of Passport picture/signature page TWO COPIES 5. ONE COPY of most recent transcript (Photocopies accepted). 6. ONE COPY of two letters of recommendation (One must come from a faculty member at your school.) 7. Non-refundable APPLICATION FEE OF $75 (make cheque or money order payable to ) Mailing Instructions Please mail all application materials to the address below before the application deadline:

4 MEDICAL EDUCATION COOPERATION With CUBA Plea se return c ompleted form to stud ent or ma il d irec tly to: ACADEMIC CREDIT CERTIFICATE Attention Applicant: Please ask the appropriate academic representative from your medical school, school of public health, or residency program to complete this form. Then return it in duplicate with your application. Attention Academic Representative: This certificate is part of a student application to the Medical Education Cooperation with Cuba () Program. offers structured electives in Cuba for students in medicine and the health sciences, as well as rotations for medical residents. Please complete this form and return it to the student. Thank you for your assistance. Student Information 1. Student Name 2. Please check appropriate program/ enrollment status/ concentration: School of Public Health Medical School Nursing School Year Year Year Concentration 3. Expected date of graduation Degree to be conferred: School Information Name of School School Address Signature I hereby certify that the above named student is enrolled in the graduate school and program named above and is in good academic standing. I also certify that the above-named student will receive elective credit upon the successful completion of the program. Name: Title:

5 Signature: Date: MEDICAL EDUCATION COOPERATION With CUBA Plea se return signed a greement with a p p lic a tion ma terials direc tly to: Participant Agreement Please read carefully I PROMISE THAT I SHALL NOT TREAT OR DIAGNOSE A PATIENT WITHOUT THE SUPERVISION OF THE PRECEPTOR OR PROFESSOR ASSIGNED TO ME IN CUBA. 1. I have carefully read the brochure and application forms. I understand that their terms and conditions are incorporated into this agreement. 2. Should I become ill or incapacitated, I agree to allow /the Cuban Ministry of Public Health (MINSAP) to take all actions necessary to procure appropriate medical services, including if need be transportation to my home or hospitalization at my own expense. 3. I agree to conduct myself professionally during the program, to cooperate with staff and my fellow participants. This includes commitment to full attendance at Monday-Friday course activities. I realize that misconduct on my part may result in expulsion from the program without refund of fees; and reiterated unjustified absences from course activities will be cause for an unsatisfactory academic evaluation. 4. I understand that, its staff or representatives are not responsible for circumstances beyond their control (including but not limited to natural disasters or phenomena, sickness, government regulations) or for actions on the part of persons not under management (such as, but not limited to, travel agencies, airlines, other governmental bodies or private corporations). I agree to exempt and its staff from all claims arising out of such actions. 5. I agree to exempt and its staff from any claims of injury while a participant in the program. 6. I agree that may modify the course program as necessary (including program dates within one week of original dates, professional activities and work/study assignments). I agree that such changes are not grounds for withdrawal from the program or for a refund. 7. I realize that it is my responsibility to complete all forms, make all travel arrangements, and submit all payments by the deadlines indicated. I agree to travel to and from Cuba on the first and last days stipulated for my elective: should this be impossible and decides to accept my application, I agree to pay airport transfers to and from the medical school where the elective is offered, and for any necessary accommodations in Havana before or after the stipulated travel dates. 8. I agree to submit the required non-refundable deposit to in the USA, and to pay the full balance upon arrival in Cuba. Should I return home before the elective is completed, I understand that a refund will ONLY be granted in case of emergency (e.g. student illness, family death or illness, or academic emergency demanding an urgent return that cannot be postponed). In case of emergency, I understand that the following refund policy will apply: if the student returns home before one third of the elective period is over, then she/he will receive a 50% refund of payments made in Cuba (not to be applied to the non-refundable deposit). After that point, no refunds will be given. 9. I recognize that it is my responsibility to obtain a valid passport, and to submit two copies of the passport photo page with my application. I agree to furnish whatever information may be requested by and its staff in order to complete application for my U.S. Treasury travel license and my Cuban visa. 10. I agree to abide by pertinent U.S. and Cuban laws, including but not limited to U.S. Treasury Department regulations governing licensed travel to Cuba and stipulating that U.S. nationals may not spend over $166 per day in Havana and $125 in the provinces. 11. I understand that my U.S. Treasury travel license and my Cuban visa are valid only as long as I am participating in the program and that any attempt by me to use these documents for other purposes is in violation of the laws of both governments. I exempt, the Cuban Public Health Ministry and their representatives from any responsibility once I have completed or left the program. 12. I exempt and its representatives from responsibility for any financial obligation I incur personally, as well as for any damage or injury that I may cause to person or property while I am a participant in the program. Name Signature Date

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