MEDICC Residency Rotation Application
Full Name (as it appears on your passport): ______
Current Mailing Address:
______
(Street) (City) (State) (Zip)
Telephone:______Email:______
Permanent Address (if different from above):
______
Birth Date: ______Birth Place:______
(dd/mm/yy) (State and Country)
Passport Number: ______Date of Issue:______
Place of Issue:______
Emergency contact: ______(Name) (Phone)
I am currently pursuing a residency in (specialty/field):______
(year): ______
at (name of the program):______
affiliated with (medical school/ hospital/ institution):
______
MD Degree from (school):______
Other post-graduate training (school/ program/degree):______
Undergraduate training (school):______
Spanish Fluency:
ÿ Native speaker
ÿ Fluent/Advanced
Total time I wish to spend in Cuba is (minimum of four weeks):______
Range of Dates Available: (please list two alternative dates):
______
(please allow MEDICC at least four months from the date you apply)
Rotation/Elective program focus (circle one, or indicate preferences in order – first choice, second choice, etc.):
1. Clinical Overview of the Cuban Public Health Care System (including community-based systems of care / The Family Doctor Program / Primary Care / visits to secondary and tertiary care institutions / epidemiological monitoring systems, etc.) with particular emphasis on/in:
ÿ Family Medicine
ÿ Pediatrics
ÿ Women’s Health
ÿ Internal Medicine
ÿ Geriatrics/Gerontology
ÿ Oncology
2. The Integration of Natural and Traditional (“Alternative”) Medicine into the Cuban Health Care System.
3. HIV / AIDS Prevention and Treatment
4. Mental Health Care in Cuba
ÿ Child and Adolescent
ÿ Adult
ÿ Both/general
OTHER: (if you have another/different specialty area of interest that does not fall into one of the above, please list it below, having selected at least one of the above. and MEDICC will work with you to develop a program that both meets your particular interests/needs and at the same time is workable in Cuba.)
ESSAY: Please write a brief statement on your expectations for the Cuba rotation, and how it will contribute to your training and future plans.
MEDICC Residency Rotation
Residency Director’s Certificate
Dear Residency Director: Please fill out this certificate and return to the applicant. Thank you.
This is to certify that ______, M.D., is a medical resident
in good standing at the (name institution)______,
and that the rotation he/she pursues in Cuba will be contemplated as part of his/her academic training.
Field of residency training:______
Current year of residency:______
Director of Residency Program (print name):______
Signature:______Date:______
Medical Education Cooperation with Cuba, Emory School of Nursing Building, Room 438,
1520 Clifton Road, Atlanta, GA 30322-4207
MEDICAL EDUCATION COOPERATION WITH CUBA
PARTICIPANT AGREEMENT
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 in this agreement.
2. Should I become ill or 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 Monday-Friday participation in my rotation. I realize that misconduct on my part can result in my expulsion from the MEDICC program without refund of fees.
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 rotation 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 on the travel dates stipulated for my elective or rotation; and in case of early arrival or late departure, to pay for the extra nights of accommodations. I further agree to pay all domestic transportation in Cuba, including travel to provinces outside Havana, airport transfers and local transportation
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 rotation is completed, I understand that a refund will ONLY be granted in case of emergency (e.g. participant’s 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 resident returns home before one third of the rotation period has elapsed, 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. 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 $180 per day in Cuban territory.
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.
______
Name Signature Date