Medical Student Application
International Elective
Name of Applicant: ______
Date of Birth: ______
Medical School:______
Year of Graduation:______
Clinical or Research Rotation? ______
Please indicate your preference of travel time as well as site location below. Please keep in mind the timing of your residency interviews as well as any courses and graduation. The application must also be signed by your academic advisor to ensure that you have met all necessary academic requirements. (Current site locations: Uganda, Zimbabwe, Russia, Vietnam)
1st Choice
Date: ______
Site Location: ______
2nd Choice
Date:______
Site Location:______
3rd Choice
Date:______
Site Location:______
We will try to accommodate your site selection. Please list any specific reasons, if any, for your site/date selections.
CONTRACT INFORMATION:
Local Mailing Address (Street, City, State, Zip Code):
______
Phone/Cell:______
Fax:______
Email Address:______
Non-Institutional Email Address (other than your university; gmail etc.): ______
Permanent Mailing Address (Street, City, State, Zip Code):
______
Phone: ______
Fax:______
Email Address: ______
IN CASE OF EMERGENCY CONTACT:
Name: ______
Phone:______
Fax:______
Email Address:______
Do you have a passport? ___Yes ___ No Date of expiration:______
Issued by which Country: ______
BIOGRAPHICAL SKETCH:
(Please include an uploaded copy of your CV with this application)
Previous Experience Abroad (Places, Dates, Purpose):
Languages Spoken (Include degree of competency; speak/listen, read, write):
Previous Community Activity (Especially during Medical School):
Career Objectives:
How will this experience facilitate your career objectives?
______
PREPARATION FOR THE PROJECT:
Please indicate below what you plan to do to prepare yourself for this international clinical elective.
- Relevant Coursework or Clinical Experience:______
- Selected Readings:______
- Language:______
- Cultural:______
- Personal Medical Preparation (Immunizations, etc.)______
***Please note that you will be required to attend two pre-departure orientation sessions, complete modules in Tropical Health, and attend a series of Global Health discussions prior to your elective, if accepted.
In addition to your clinical work during the elective, please indicate any cultural opportunities you hope to also pursue during this elective.
______
Academic Advisor Signature: ______Date:______
We require three (3) letters of recommendation along with this application.
If you have any questions about the application, please contact Gina Lacey at .
APPLICATION CERTIFICATION AND ACCEPTANCE: I certify that the statements herein are true, complete, and accurate to the best of my knowledge, and I agree to comply with the Medical School and University terms and conditions if an award is issued as a result of this application.
Signature: ______Date:______
Academic Advisor’s Printed Name: ______
Academic Advisor’s Signature: ______
GLOBAL HEALTH PROGRAM
Hold Harmless Agreement
I hereby elect voluntarily and on my own initiative to travel through the Western Connecticut Health Network, Inc. Global Health program based at The Danbury Hospital. I acknowledge that I bear full responsibility for any personal injury or illness, accident, risk or loss or property damage that may be sustained by me in connection with my participation in the above mentioned program. In particular, I acknowledge and am fully aware of the risks and hazards associated with my travel, including without limitation, risks abroad. I acknowledge and agree that Western Connecticut Health Network, Inc., The Danbury Hospital, their respective affiliates, are not and will not be responsible for any illness, injury, accident, damage or loss suffered by me from or in connection with my participation in the program and hereby release and agree to hold harmless Western Connecticut Health Network, Inc., The Danbury Hospital, their respective affiliates, its officers, directors, employees and agents from any and all liability, claims, demands and actions arising or related to any loss, property damage, illness, injury or accident that may be sustained by me in connection with or during my participation in the above mentioned program.
I further acknowledge and certify that I have adequate health and accident insurance covering myself and my property both domestically and internationally.
This release and hold harmless agreement is and shall be binding on myself and my heirs, assigns and personal representatives.
______
Signature
______
Participant Name (Please Print)
______
Address
______
City, State, Zip
______
Phone Number
______
Date (Month/Day/Year)
Please deliver or mail original to: Danbury Hospital c/o Gina Lacey, Medical Education and Global Health Department Floor 6 South, 24 Hospital Avenue, Danbury, CT 06810
GLOBAL HEALTH APPLICATION CHECKLIST
Please be sure you have completed all of the following:
□Completed application
□Academic Advisor’s Signature
□Attached 3 Letters of Recommendation
□Attached current CV
□Completed and signed Hold Harmless Agreement
Once you have all of the above, please mail the originals to:
Gina Lacey, Coordinator
Western Connecticut Health Network
Danbury Hospital
24 Hospital Avenue, 6 South
Danbury, CT 06810