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 choose from the following specializationsin the order of your preference for the placement. Please note that your first choice may not be guaranteed.


Option 1 (name of specialization)
Option 2 (name of specialization)
Option 3 (name of specialization)


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? If yes, please explain



CV:

Letter of intent: