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GLOBAL HEALTH:
CLINICAL AND COMMUNITY CARE

Course Home

 How to Apply Links to GH Programs Links to IH Sites

Please Mail or Submit This Form No Later Than February 15 for April 1-23 session and May 15 for July 12-30 session.

I am applying for   ____  April      _____ July

I. Applicant Information
Today's Date
Name
Address
City, State, Zip

Medical or other health professional    School
 
MONTH and YEAR of expected (or prior) graduation
Telephone
FAX
E-mail
   
II. Please write a statement explaining your interest in developing nation health:
(If you are mailing this application, attach a separate sheet of paper.) 
This statement is considered in the selection process.
 
III. Prior Experience in developing nations: (This will not affect your selection)
Nation Date and Time Spent Purpose (tourist/work/study/other)
 
IV. Do you have a future elective scheduled in a developing nation?
     (This may be considered in your selection.) 
Yes or No 
If Yes: 1) How firmly set? 
2) What nation(s)? 
3) When? 
   
V. Any special background interest or needs we should know of?
     (These details will not affect your selection.)
 
VI. How did you find out about this course?

After SUBMITTING APPLICATION,
click your browser's Back button to
return to the Global Health Web site.
 

OR RETURN APPLICATION TO:

Ronald E. Pust, MD
Global Health Course Director
Department of Family and Community Medicine
The University of Arizona College of Medicine
PO Box 245052
Tucson AZ 85724 USA

 
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Last modified: 9/1/09