Last Name First Name
Middle Name
Country
Mailing Address
Phone number
Email
Male
Female
Profession of
Applicant :
Medical
Student
Senior
Medical Student
Resident
Medical Doctor
Senior
Physician Assistant Student
Other Health
Professional or Student
Name of Student´s Home Institution
Where do you work or
study? Please describe briefly what you do:
My Spanish command
is (Please check the appropriate):
Very Good
Good
Not Very Good
Beginner or lower
Have you had any
other Spanish training before?
Yes
No
If the answer
to the previous question is YES... What type of
trainning did you have?
Immersion in a Spanish speaking environment
Self
direct course
University/College Intensive Course
High
School course
Other
How long ago did you
attend the training?
Six Months
One Year
More than 2 years
Have you taken a
course in Tropical Medicine before?
Yes
I took a specific course
Yes, as part of the Medical School Curriculum
No
Which session of the
“ Latin Spanish Patient” Medical Spanish Course would you like to
attend:
Month
Year
December is only open
to special groups. Ask for more information to info@ihcai.org
Another date?
Please indicate:
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 write a brief
description of what you consider to be the more important problems of
medicine and health care in the third world countries and what you think
are the advantages of the developed countries. (You may write in English,
but no more than 100 words please):
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 the person to be contacted in case of an
emergency.
Name,
current mailing address, phone, and email (if available).
