UVM Larner College of Medicine Global Health Elective Application

Application for the Global Health Elective

Thank you for your interest in participating in a Global Health experience organized by the Nuvance Health/UVMLCOM Global Health Program. Please take a few minutes to complete the application form provided below. There are three sections that you will need to complete. IMPORTANT: Prior to initiating this application, please make sure to have the following documents available and saved on your computer and ready to upload: 1) A color copy of your passport (photo page); 2) Your current curriculum vitae; 3) A one-page motivation letter explaining your interest in participating in the Global Health elective and the expectations that you have in regard to this program. Thank you!
Section 1. Personal Information
Full Name (as shown in passport)*
First Name Middle Name Last Name
Date of Birth (as shown in passport)*
MM/DD/YYYY
Citizenship*
Do you have a passport valid for international travel?*

YesNo
Passport expiration date*
MM/DD/YYYY or N/A
Passport number*
Please provide your mailing address.*
Is your residence address the same as your mailing address (provided above)?*

YesNo
Residence address
If different from mailing address provided above
Cell phone number*
Official university email address*
example@example.com
Alternative E-Mail address (This address will be used only for one of three purposes - in case of an emergency during the elective, if we need to send you large size files, or when we need to contact you as an alumni of the program after you've graduated. For all other communication purposes we will be using your official University email address)*
example@example.com
Please indicate your current medical training level.*

Medical Student - 1st yearMedical Student - 4th year
Do you speak another language other than English? If yes, please specify. *
language(s) spoken or N/A
Have you had past International or Global Health experience(s) abroad?*

YesNo
Please provide details regarding your past International or Global Health experience(s). Include countries visited, dates, aim and purpose of travel, main learning points, etc. *
If none, enter N/A
Please speak of any preferences you have for site placement*
Please indicate the preferred start date of the elective. *Please note that the Global Health elective is typically 6 weeks*

MonthDayYear
Date
Do you give permission for the Global Health Leadership Team to discuss your application with your PCR mentor?*

YesNo
Section 2. Health Insurance Information and Emergency Contact Information
Please specify the company that provides your medical insurance.*
Does your medical insurance policy cover travel medical expenses?*

YesNoNot sure *Please note you are responsible for ensuring that you have medical insurance coverage for your travel
In case of emergency, please provide the name of a person we can contact. *
Please identify your relationship to the person listed above as the emergency contact.*
Please provide the address for your emergency contact person. *
Please provide a phone number for your emergency contact person. *
Section 3. File Upload
Please upload a color scan of the front page of your passport (PDF or JPEG files are acceptable).*

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Please upload a 1-page motivation letter, explaining your interest in participation in the Global Health elective and the expectations that you have in regard to this program (DOC, DOCX, PDF, or JPEG files are acceptable).*

Browse Files

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Please upload your most current Curriculum Vitae (CV) (DOC, DOCX, PDF, or JPEG files are acceptable). *

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Sign and Submit Application Form
By signing this form, I confirm that the information contained herein is correct to the best of my knowledge. *
Please type your full legal name here
Please tick the box below*
Should be Empty:

Application for the Global Health Elective