Please read all the instructions and requirements carefully before completing this form!

    Please choose the program you wish to apply to:

    P 001 CR International Health Community Based Rotation for Senior Medical Students in Costa Rica P 001 HN International Health Community Based Rotation for Senior Medical Students in Honduras P 002 Community Based Health Research or Intervention P 003 A International Health Community Based for Physician Assistants of Pacific University P 003 B International Health Community Based for Physician Assistants P 008 CR International Health Community Based Rotation for Residents in Costa Rica P 008 HN International Health Community Based Rotation for Residents in Honduras P 017 A Nutrition and Rural Medicine in Latin America for Senior Harvard Medical Students ME 518 P 020 A MSU/CHM International Medicine Elective MED 629 P 020 B MSU/CHM Advanced International Medicine Elective MED 631

      Last Name    First Name    Middle Name

      Country

      Mailing Address

      Phone number

      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.

    Spanish is: (Please check the appropriate)

      Mother tongue

      Very Good

      Good

      Not Very Good

    Did you attend any Spanish training?

      Yes

      No

    What type of training did you attend?

      Immersion in a Spanish speaking environment

      Self direct course

      University/ College Intensive Course

      High School course

      Other

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

    How long ago did you attend your training?

      Six Months

      One Year

      More than 2 years

•     It is mandatory to have a moderate level of Spanish in order to do a clinical rotation. 

              IHCAI may request proof of the Spanish proficiency level.

    If you are planning to work on a project, please write a list of subjects proposals (in order of preference). 

    All Tulane & HarvardMedical students must answer this question. Students from other schools who wish to work on a project 

    must obtain a project approval from IHCAI.

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

      Yes          No

    If yes, please indicate the amount:

      in US $

    Do you need funding from IHCAI or from another institution for your project?

      Yes          No          Do not know

    Please indicate the period during which you wish to study at IHCAI:

    From  To    Number of weeks:

    Please write your motivational statement in the field below (no more than 100 words). If you feel that your Spanish is not

    adequate you may write it in English.

    Please indicate any special requests, such as medical conditions needing particular attention, food restrictions or requests,

    religious preferences or any other special needs below.

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

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

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