Global Health Program – Application form

Cluj School of Public Health project

    Contact Information

    First Name
    Last Name
    Middle Name
    Primary E-mail
    Alternate E-mail
    Primary Phone
    Alternate Phone
    Date of birth
    Gender
    Ethnicity

    Current mailing address (where you receive mail during the academic year)

    Street address
    City, Country, ZIP

    Permanent mailing address

    Street address
    City, Country, ZIP

    Emergency contact information

    Name(s)
    Address, City, Country, ZIP
    Primary Phone
    Alternate Phone
    Relationship (e.g. parents, spouse)
    E-Mail

    Academic information

    Major (Area of study)
    Second Major/Minor (if minor)
    Emphasis Area/Other
    Degree Awarded
    Graduation Year


    If you have any comments you would like to make about your academic record, please do so in the space provided below:


    Comments:


    Please read the following statements, as well as sign and date this page. If you have any questions regarding the following, please contact our office.

    I understand that, if selected to participate in the Global Health Practicum Program, I must successfully complete an online training course regarding the responsible conduct of research prior to the internship departure date.

    I acknowledge that if I choose to conduct my own research project with human subjects, I must complete an IRB application and this application must be approved prior to the internship departure date (please contact our office immediately if you have any questions or concerns regarding IRB application and approval process).

    Please upload the signed statement here:

    Internship information

    Time period for when you want to undertake the internship(example: 2016-01-31):
    -


    Please rank the first 3 options (activities to undertake during the internship) in the order of your preference for the placement. Please note that your first choice may not be guaranteed.


    Option 1
    Option 2
    Option 3


    Do you have any illnesses, allergies (life threatening only), or other medical conditions that need or may need continuous medical supervision or may prevent you from completing an overseas internship?

    YesNo

    If yes, please explain



    CV:

    Letter of intent: