Application for THE WOMEN’S HEALTH ELECTIVE

MEDICAL EDUCATION COOPERATION

With CUBA

Dates of MEDICC Elective you are applying for:

Passport InformationPlease 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)

  1. Gender: OMale O Female 3. Birth date: 4. Place of birth:

Month / Day / Year State/province, country

  1. Passport Number:6. Date of issue:

Month / Day / Year

  1. Place of issue:8. Date of expiration:

Month / Day / Year

Personal Information

Email Address Please provide your complete email address, making sure to clearly indicate capital lettersand numbers.

  1. Current Mailing Address

CityStateZip Code

/

  1. Home Telephone Number /Daytime Telephone Number
  1. Permanent Mailing Address (if different from current address)
  1. Ethnic Status: Choose one that best describes you. Your response is voluntary, and will help us assess diversity in MEDICC.

O Black or African American O Hispanic or Latino

O Native American/Alaska NativeO Asian/Pacific Islander

O White/CaucasianO other

Education & TrainingPlease print clearly

  1. I am currently enrolled in:

O Medical School (year) O Nursing School (year) O other

  1. Name of School
  1. School Mailing Address
  1. Additional Training: InstitutionLocationDegree/Date received
  1. List any special awards, honors or fellowships you have received
  1. List memberships in professional and social service organizations

Experience

  1. List experience in developing countries (other than vacation time)
  1. List local/community service
  1. List other pertinent experience

Professional Interests

  1. Please rank (1st, 2nd, 3rd) the fields that most interest you in Cuba

Family Planning, Abortion Counseling Services

Maternal and Infant Programs

STD and AIDS Programs

Clinical Experience in OB/Gyn

23b. List possible areas of specialization in the future

Spanish Proficiency

Note: All MEDICC classroom and fieldwork is conducted in Spanish.

  1. 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

  1. List the names of the individuals that will write your recommendation letters.One must be a faculty member at your school.

NameTitleRelationship

Address

Day PhoneEmail address if available

NameTitleRelationship

Address

Day PhoneEmail address if available

Medical InformationPlease print clearly

  1. Are you currently taking any prescription medications? yes___ no____
  2. Do you have any special dietary needs? yes_____ no_____

If yes, please specify:

  1. Do you have any allergies to food or medicine? yes____ no_____

If yes, please specify:

  1. Are you currently under the care of a physician for a chronic medical condition? yes____ no______

If yes, please specify:

Signature

  1. 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 MEDICC program.

______

Applicant signature Date

Essay Requirement

  1. Please answer both (A) and (B).

(A) Why are you qualified to be a participant in the MEDICC 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 MEDICC 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) ORIGINAL and ONE COPY
  2. Signed and dated Participant Agreement ORIGINAL and ONE COPY
  3. Completed Academic Credit Certificate (to be completed by appropriate university office) ORIGINAL
  4. Photocopy of Passport picture/signature page TWO COPIES
  5. Most recent transcript (Photocopies accepted). ONE COPY
  6. 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 “MEDICC”)

Mailing Instructions

Please mail all application materials to the address below before the application deadline:

MEDICC
Emory School of Nursing Building

Room 441

1520 Clifton Road
Atlanta, GA 30322-4207


MEDICAL EDUCATION COOPERATION

With CUBA

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 (MEDICC) Program. MEDICC 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
  1. Please check appropriate program/ enrollment status/ concentration:

School of Public HealthMedical SchoolNursing School

YearYearYear

Concentration

  1. Expected date of graduationDegree 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 MEDICC program.

Name: ______Title: ______

Signature: ______Date: ______

MEDICAL EDUCATION COOPERATION

With CUBA

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 MEDICC brochure and application forms. I understand that their terms and conditions are incorporated into this agreement.

2. Should I become illor incapacitated, I agree to allow MEDICC/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 MEDICC 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 MEDICC program without refund of fees; and reiterated unjustified absences from course activities will be cause for an unsatisfactory academic evaluation.

4. I understand that MEDICC, 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 MEDICC management (such as, but not limited to, travel agencies, airlines, other governmental bodies or private corporations). I agree to exempt MEDICC and its staff from all claims arising out of such actions.

5. I agree to exempt MEDICC and its staff from any claims of injury while a participant in the MEDICC program.

6. I agree that MEDICC 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 MEDICC 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 MEDICC 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 MEDICC 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 MEDICC 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 MEDICC, the Cuban Public Health Ministry and their representatives from any responsibility once I have completed or left the MEDICC program.

12. I exempt MEDICC 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 MEDICC program.

NameSignature Date