Student and VolunteerApplication Form

Name: / Application Date:
School:
Degree: / Year of Graduation:
Purpose (i.e. clinical rotation, public health practicum):
Preferred Dates: / To: / Flexibility on Dates? Yes No
Institutional E-mail: / Personal E-mail:
Age: / Citizenship:
Current address:
Phone # (home/cell): / Phone # (work):
Skype Username: / Gender: Male Female Decline
Are you hoping to attend simultaneously with someone else? (If yes, who?):

Personal Information:

Language Proficiency:

Using the criteria below, please rate your language proficiency by marking the appropriate box:

Language / Fluent / Conversant / Intermediate / Beginner
English
Spanish
Haitian Kreyol
French
Other (specify)

Resume / CV:

Please include an updated version of your resume as part of this application.

Brief Essay:

Please write and attach a single-spaced essay of no fewer than 400 words and no more than 600 words on why you are applying to participate with Clinica de Familia La Romana. You should include any special areas of interest that you would like to pursue, additional skills and experiences that you may want to highlight and anything else you consider relevant. If applicable, please also include a description of your proposed project in this essay.

Examples of topics you may want to cover are:

  • What are your professional and personal goals and how does this experience further those goals?
  • What is your experience with the language and culture of the Dominican Republic?

APPLICATION INSTRUCTIONS

Your complete application should consist of the following documents:

  1. Completed Application
  2. CV / Resume
  3. Essay

Please save the application and supporting documents as PDF or Word documents in the following way:

  • Application: “First Name, Last Name, Application”
  • Personal Essay and CV in one document: “First Name, Last Name, Essay and CV”

Applications and supplemental documents should be emailed to: and

1

Updated February 2015

LANGUAGE PROFICIENCY CRITERIA: Fluent: native speaker or very advanced non-native speaker; can take a medical history and understand everything a patient and relatives say; can give a lecture on a familiar subject in the language, as easily as in your native language; can write a report with correct grammar. Conversant: can understand much of what's going on, but would not be able to give a lecture without practice; can communicate, administer questionnaires, and instruct patients on taking medicines; can write notes in Spanish, fill out forms. Intermediate: can order food and get around, but help is needed in detailed communication, such as comforting afamily member, following guidelines in the non-native language, or participating in a meeting; can follow an adult conversation much of the time. Beginner: can form some sentences and understand simple comments or commands; an interpreter is needed for most interactions.