Submitted by sjaxon on Thu, 09/15/2022 - 13:02 Please submit this form no later than July 15. Indicates required field Enrollment Options Global Health Intensive Course (MED 896A) Enrollment Date: 9/25/23 – 10/13/23 Global Health ONLINE Intensive Course (MED 896O) Enrollment Date: 7/31/23 – 10/20/23 Name First Name Last Name Mailing Address Email Phone Number Phone Ext: List the Medical or Graduate School Attended Year of graduation (or last year of attendance) Statement of Interest Required: Please tell us about your interest in health care in developing nations. One paragraph only, please. Do you have prior experience in developing nations? Yes No If yes, tell us about the developing nations you've visited Nation Visited (1) The name of the first developing nation in which you have spent time (if applicable). Year(s) visited and time spent (1) Purpose of visit (1) -SelectStudyTourismWorkOther (please specify) Other purpose (1) Tell us about the second developing nation you've visited. Nation Visited (2) The name of the first developing nation in which you have spent time (if applicable). Year(s) visited and time spent (2) Purpose of visit (2) -SelectStudyTourismWorkOther (please specify) Other purpose (2) Tell us about the third developing nation you've visited. Nation Visited (3) The name of the first developing nation in which you have spent time (if applicable). Year(s) visited and time spent (3) Purpose of visit (3) -SelectStudyTourismWorkOther (please specify) Other purpose (3) Do you have a future experience scheduled in a developing nation? Yes No If yes, tell us about your future experience plans How firm are these future plans? Firm Still negotiating dates Waiting to hear back from contact What nation do you plan to visit? When do you plan to visit? Other interests or needs Is there anything else about your background, interests or needs we should know? This will not affect your selection. How did you find out about this course? Submit Leave this field blank
