Department of Family Medicine - International Health Elective
Application
Name (as it appears on your passport):
Home Address:
City:
State:
Zip:
Home Phone:
Cell phone:
Pager:
Email:
Name, Address, Phone Number, and Relationship of Nearest Relative:
Name:
Address:
Phone:
Relationship:
Your Occupation:
faculty physician
resident physician
medical student
dental
nurse
volunteer
construction
other
If construction, what type?:
If other, Please specify:
If medical student, which school:
If student, have you submitted enrollment request on medonestop?
yes
no
Do you have previous international health experience?
yes
no
If you have experience, where was it acquired and in what capacity?:
Do you speak a foreign language?
yes
no
If so, please specify:
How well do you speak the language specified:
proficient
can converse
minimal
Other abilities, hobbies or interests relevent to an international rotation:
If you have any medical conditions, please list:
If you have any dietary restrictions, please list:
Are you willing to serve in any capacity (on a short term basis) at the site if asked: (e.g., work in the kitchen, pharmacy, triage, community interviews, etc?
yes
no
Tell us why you are interested in the international health elective (essay form, 1 to 2 paragraphs.)
Choose your month and site:
Brazil - April ($2600)
Tanzania - October ($2800)
Honduras - May ($1450)
Honduras - October ($1450)