UVM LARNER STUDENT GLOBAL HEALTH APPLICATION
Full Name (as shown in passport)
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First Name
Last Name
Date of Birth (as shown in passport)
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Month
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Day
Year
Date
Citizenship
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Do you have a passport valid for international travel?
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Do you have a passport valid for international travel?
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Passport expiration date
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Month
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Day
Year
Passport must be valid at least 6 months beyond your travel dates.
Passport number
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Cell phone number
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Please enter a valid phone number.
Format: (000) 000-0000.
Official university email address
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example@example.com
Alternative email address
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This email address will be used in case of emergency.
Do you speak another language other than English? If yes, please specify.
Have you had past International or Global Health experience(s)?
Please provide details regarding your past International or Global Health experience(s). Include countries visited, dates, purpose of travel, main learning points.
Please indicate the preferred start date of the elective. M4 Rotation only.
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Month
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Day
Year
Please note the GH elective is typically 6 weeks. If you are an M1 please leave this question blank.
Do you give permission for the GH leadership team to discuss your application with your PCR mentor.
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Please specify the company that provides your medical insurance.
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Does your medical insurance policy cover travel medical expenses
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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.
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Please provide the relationship to you of the person listed as your emergency contact.
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Please provide the email address for your emergency contact person.
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example@example.com
Please provide the phone number of your emergency contact person.
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Please enter a valid phone number.
Format: (000) 000-0000.
Please upload a color scan of the front page of your passport.
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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.
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Please upload your most current Curriculum Vitae (CV)
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By signing this form, I confirm that the information contained herein is correct to the best of my knowledge.
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