Lea cuidadosamente las instrucciones antes de llenar esta fórmula!

    Please choose the program you wish to apply to:

    P 007 Clinical Rotation for Central American Senior Medical Students at Tulane School of Medicine P 017 B Clinical Rotation for Central American Senior Medical Students at Harvard Medical School P 018 Clinical Rotation for Central American Senior Medical Students at European Medical Schools & Research Institutes

      Last Name    First Name    Middle Name

      Country

     Passport or ID number

      Mailing Address

      Phone number

     Mobil Phone

      Email

      Male          Female

    Information about your Home Institution

    Name of your Advisor

      Name of Home Institution

      Mailing Address

      Phone number

      Email

      Please indicate your year of graduation.

    English is: (Please check the appropriate)

      Mother tongue

      Very Good

      Good

      Not Very Good

    Did you attend any English training?

      Yes

      No

    What type of training did you attend?

      Immersion in a English speaking environment

      Self direct course

      University/ College Intensive Course

      High School course

      Other

    For how long did you attend the English classes? How many hours per week?

    How long ago did you attend your training?

      Six Months

      One Year

      More than 2 years

    Have you approuved the Toffel Test?

     Yes        Date              Score 

     No

•     It is mandatory to have a high level of English in order to do a clinical rotation. 

              IHCAI may request proof of the English proficiency level.

    Do you have a grant for your project from your home institution?

      Yes          No

    If yes, please indicate the amount:

      in US $

    Please indicate the period during your rotation:

    From  To    Number of weeks:

    Please write your motivational statement in the field below (no more than 100 words) in English.

    Please indicate any special requests, such as medical conditions needing particular attention.

    Emergency contact information. Please indicate a person to be contacted in case of an emergency.

    Name, current mailing address, phone and email (if available).

Information and terms of reference upon request compliting this application does not garantee that the student has not been accepted.

Please make sure you have answered EVERY question before sending this form