The University of Toledo College of Medicine Global Health

The University of Toledo College of Medicine Global Health

The University of Toledo College of Medicine – Global Health

Student Form 1: Request for Global Health Experience

To be completed by student requesting a global health experience at an approved global health site. If this request is not received by the Office of Global Health at least 4 months before your desired departure date, it may be denied.

Name ______Rocket Number R______

Program ______

I would like to have a global health experience at:

Rank / Global Health site location / Desired Month / Specialization (e.g., Emergency Medicine)
1st choice
2nd choice
3rd choice

UT COM faculty supervisor you are working with:

*If you are requesting an approved international Global Health rotation sponsored by the Office of Global Health, your faculty supervisor will be Dr. Kris Brickman unless you are participating in one of our approved recurring medical missions. Please list your faculty team leader as your faculty supervisor for all approved UT COM medical missions.

______

Your preferred email, phone number, and address:

*Please use only one preferred email address when corresponding with Deb Krohn.

______

______

I will complete all additional UT COM Global Health Forms (2 – 6) and any other documentation the Office of Global Health requests. Additionally, I will attend mandatory pre-departure orientation(s) affiliated with this trip. I understand that by not fully completing the aforementioned steps by the required deadlines (set through the Office of Global Health) my request for a global health experience may be denied.

I will have the funding required to go on this trip in hand at least 2 months before departure. Most trips cost between $2/3000; check the description of those you are interested in to confirm. Up to $1200 may be available in the form of a travel grant from The University of Toledo’s Center for International Studies and Programs (CISP) Office. Please reference the Travel Grant website at http://www.utoledo.edu/cisp/travelgrant/ for application deadlines or call the CISP Office at 419.530.5268 for additional questions.

Signature: ______Date: ______

*** YOU MUST PROVIDE DEB KROHN, GLOBAL HEALTH ADVISOR, WITH PROOF OF GOOD ACADEMIC STANDING. TO EXPEDITE THIS PROCES, YOU MAY EMAIL THE HSC REGISTRAR, AT . PLEASE NOTE THAT YOUR EMAIL REQUEST TO THE REGISTRAR CAN ONLY COME FROM YOUR UT ROCKETS EMAIL ACOUNT AND MUST INCLUDE THE FOLLOWING: NAME, ROCKET NUMBER, EXPECTED GRADUATION DATE, AND PROGRAM OF STUDY. UPON RECEIPT, THE REGISTRAR WILL SEND DEB AN ELECTRONIC COPY OF YOUR PROOF OF GOOD ACADEMIC STANDING. ***