STUDENTS' INQUIRY FORM
Full Name
*
First Name
Last Name
Email
*
example@example.com
Country of residence
*
Citizenship
*
Phone Number
*
Please enter a valid phone number.
Date of Birth
*
-
Month
-
Day
Year
Date
Highest level of academic completion
*
Medical degree you are interested in:
*
Please Select
Doctor of Medicine
Doctor of Dentistry
Nursing
Medical Postgraduate/ Residence
How are you planning to support yourself financially during your academic studies?
*
Please Select
- I will support myself/ my family will support me
- I will be receiving a scholarship from my government
- I will be receiving a government-backed loan
Starting date (please note all Cuban academic programs start in September)
*
-
Month
-
Day
Year
Date
Do you speak Spanish?
*
Yes
No
IMPORTANT REMINDERS:
The Cuban scholarship program ended in October 2010.
CubaHeal will not be able to attend to recipients of scholarship or students seeking scholarship. If you are receiving a scholarship, please do not fill the application out and disregard this form.
Submit
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