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Program P010A Application Form
 
"The Latin Spanish Patient in the Environment of Tropical Medicine"
Intensive Medical Spanish Course and Introduction to Evidence Based Tropical Medicine

 

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

 

 

  Last Name    First Name    Middle Name

 

  Country

 

  Mailing Address

  Phone number

  Email

  Male          Female

Profession of Applicant :

  Medical Student »                              Please indicate your year of graduation:   

  Resident

  Medical Doctor

  Physician Assistant Student »          Please indicate your year of graduation:   

  Physician Assistant

  Nurse student  »                                 Please indicate your year of graduation:   

  Nurse

  Other Health Professional or Student  »     Please indicate:    

   Name of Home Institution

Where do you work or study?  Please describe briefly what you do:

 My Spanish command is (Please check the appropriate and remenber we accept all the levels of Spanish):

  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 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.

Only for advanced students in Spanish: 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. (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, phone and email.

 

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

 

 

   
International Health Central American Institute
Foundation

IHCAI Foundation has its headquartes in San José, Costa Rica, Central America.

IHCAI Foundation is an equal opportunity organization and do not make

any preference by gender, race, sexual orientation or political opinions

and rejects those openly racist, Nazi or Neo Nazi oriented.

 

IHCAI - Main Office

P.O. Box 1677-2100, San José, Costa Rica,
Barrio Escalante, San Jose, 7th Avenue, 35 and 37 Street, #3530

Tel:  (506) 2234-6354 or (506) 2234-6347   //  Fax:  (506)2226-3047

Email: info@ihcai.org

http://www.ihcai.org