OFFICIAL STUDENT APPLICATION FOR ADMISSION INTO A POSTGRADUATE MEDICAL PROGRAM

APPLICANT INFORMATION AND PREFERENCES:

Today's date*

MonthDayYear

Applicant's full name*

Gender*

Country of birth*

Street Address

Street Address Line 2

Country

Mother's name*

Country of birth*

Street Address

Street Address Line 2

Country

Father's name*

Country of birth*

Street Address

Street Address Line 2

Country

Full address*

Street Address Line 2

Country

Telephone number*

Passport number*

Personal identification and Cuban ID (if applicable):*

E-mail*

Date of birth*

MonthDayYear

Citizenship*

Passport number

A valid passport would be required at a later stage of the registration

Passport issuance date

MonthDayYear

Passport expiry date

MonthDayYear

Current occupation*

ACADEMIC BACKGROUND:

Current Occupation*

Baccalaureate Degree*

University graduation date (baccalaureate or equivalent level)*

MonthDayYear

Institution which certified your studies*

Name and address of the university/ medical science faculty to which you belong to*

Other medical studies/ training you are currently enrolled in or you have concluded:*

Are you a certified medical practitioner? *

If you are a certified medical practitioner, what is your medical specialty? (Describe / If not applicable, please enter "None")*

If you are a certified medical practitioner, what medical institution/ research facility do you belong to? (Describe / If not applicable, please enter "None")*

Date of graduation (pre-university/ high school or equivalent) *

MonthDayYear

Additional notes (If not applicable, please enter "None")*

REQUESTED ACADEMIC PROGRAM DETAILS

Postgraduate Program *

If the program you are interested in is not available in the above "Post Graduate Program's" drop down menu, kindly list it below:

please visit https://www.cubaheal.com/diplomas-training-courses-visits-fellowship-and-internships/ and select the exact program you are interested in

If you are interested in Visits, Residency, or Internships programs, please furnish full details (Describe / If not applicable, please enter "None")

please visit https://www.cubaheal.com/diplomas-training-courses-visits-fellowship-and-internships/ and select the exact program you are interested in

If interested in a Doctoral program, state the Research topic (should be related to scientific subject of the country of origin of the applicant)

First enrollment date preference*

MonthDayYear

Enrollment total number of weeks (for training programs only)

Second enrollment date preference*

MonthDayYear

Enrollment total number of weeks (for training programs only)

Third enrollment date preference*

MonthDayYear

Enrollment total number of weeks (for training programs only)

Is Spanish your mother tongue?*

Please be aware, for Non-Spanish speaking students, you would be required to enroll in a 3 months Spanish course

PAST RESIDENCY DETAILS

In the past, have you been enrolled in any educational program in the Republic of Cuba? *

If in the past you have been enrolled in an educational program in the Republic of Cuba, please type in the date you have departed the country? If you have not been enrolled, please type N/A *

If in the past you have been enrolled in an educational program in the Republic of Cuba, please choose the mean of departure? If you have not been enrolled, please choose N/A?*

Please be aware, for Non-Spanish speaking students, you would be required to enroll in a 3 months Spanish course

CONTACT PERSON IN CASE OF EMERGENCY

Full Name

Relationship*

E-mail

Phone Number

Full address*

Street Address Line 2

Country

ACCOMMODATION PREFERENCE

Note: Accommodation in a university residency is compulsory for the first year of an undergraduate program in any medical specialty. Those starting an undergraduate program must choose one of the following two options:
1- University Residency in Cojímar (for students starting premed and Spanish courses students); or
2- Residency (for students starting medical careers)

Accommodation preference*

Do you prefer to live alone?*

HAVE YOU/ DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS

Lung disorder*

High blood pressure*

Heart condition*

Disease of the kidney*

Malaria*

Any form of cancer*

Disease or disorder of the digestive tract*

Diabetes*

Chronic hepatitis with positive antigen*

Marked Cifo- scoliosis *

Dwarfism *

Rhinolalia*

Acromegaly*

Pemphigus*

Leprosy*

Chorea or Athetosis*

Ankylosis of large joints*

Retinitis Pigmentosa*

Blepharospasmor Bilateral Ptosis*

Generalized Dermatitis*

Ataxia*

Sever Epilepsy *

Paralysis of limbs*

Congenital Glaucoma*

Bilateral Congenital Cataract*

Bilateral severe hearing loss *

kyphosis *

Mental deficiency of any degree*

Cyanotic Congenital Heart disease*

Voice and/ or speech disorders *

High degree of stuttering*

Any kind of active Tuberculosis*

Discoid Fixed Lupus Erythematosus *

Amputation of the fingers in one or both hands affecting manual skills*

Personality disorders in a permanent state of inadequacy or frequent periods of decompensation*

Total amputation of limbs or segments of members, excluding lower limbs that are partial and do not require the use of prosthesis*

Curvature, shortening or lengthening of members that limit their functions or wearing of special uniforms or footwear*

Aftermath of traumatic injuries, burns or surgery, or keloid scars shrink, which makes movement difficult or produce functional disability or serious aesthetic problems or interfere with wearing special uniforms or shoes*

Genodermatosis, Ichthyosis (according to location and extent of the injury). Epidermolysis Bullosa, Xeroderma Pigmentosum, Von Recklinghausen disease*

Psychiatric disorders in the form of permanent or frequent seizures despite treatment*

Congenital Malformations or permanent disfigurements due to any cause*

Sickle Cell Anemia(Sicklemia), Hypoplastic or Aplastic Anemia*

Congenital or acquired Heart disease with physical limitations*

Any sexually transmitted Diseases? (Describe / If not applicable, please enter "None"). Please note all students will undergo laboratory testing to confirm the absence of any STD *

Do you suffer from any psychological disorders (Describe / If not applicable, please enter "None"). *

Do you suffer from any life threatening allergies (Describe / If not applicable, please enter "None").*

Do you suffer from any behavioral or substance abuse or addiction to psychoactive substance prohibited by Republic of Cuba's laws? (Describe / If not applicable, please enter "None").*

Disease or disorder of the blood?(Describe / If not applicable, please enter "None")*

Any physical disability or deformity? (Describe / If not applicable, please enter "None")*

Any vision or hearing disorder?(Describe / If not applicable, please enter "None")*

Any life-threatening conditions? (Describe / If not applicable, please enter "None")*

Any contagious disease? (Describe / If not applicable, please enter "None")*

Have you had or been advised to have a surgical operation within the last five years? (Describe / If not applicable, please enter "None")*

Any other special medical information (Describe / If not applicable, please enter "None") *

Do you have any special diet (Describe / If not applicable, please enter "None") *

Date of last tetanus shot:*

MonthDayYear

UPLOAD:

If you are interested in Visits, Residency, or Internships program(s), please disregard the upload section below

Copies of entry registration or medical license status

Upload a File

Copies of pre-university studies 1

Upload a File

Copies of pre-university studies 2

Upload a File

Certified and legalized copies of Immunization report

Upload a File

POLITICAL AFFILIATION

HOBBIES and INTERESTS

IMPORTANT NOTICE REGARDING THE INITIAL DEPOSIT:

Starting August 1, 2015, please be advised that CubaHeal will request a $200.00 CAD initial deposit for the submission of STUDENT APPLICATION FOR ADMISSION INTO A POSTGRADUATE MEDICAL PROGRAM to the Cuban Academic Services Authorities (CASA) for assessment. This is due to the fact that it has come to our attention that a number of applicants who have been granted enrollment approval in Cuba were only interested in receiving free consultation. In our opinion, this is an unfair conduct since

- The Cuban Academic Services Authorities (CASA) have taken the time to review and assess the applicant’s file and
- Possible assignment of enrollment or visits spots for an applicant which could result in creating a longer waiting period for other students and visitors.
Furthermore, please take note should the Cuban Academic Services Authorities (CASA) refuse an enrollment, CubaHeal will refund the total amount within two business days
KINDLY BE AWARE, CUBAHEAL UTILIZES ITS PAYMENT PROCESSING SERVICES VIA our SISTER COMPANY CHMT Canada Inc., OUR SISTER COMPANY. IN YOUR CREDIT CARD STATEMENT, YOU WOULD NOTICE THE NAME CHMT Canada Inc AS THE BENEFICIARY.

CubaHeal Education team

Payment

POST-GRADUATE MEDICAL PROGRAM$200.00CAD

APPLICATION FOR ADMISSION INTO A POST-GRADUATE MEDICAL PROGRAM

Total $0.00CAD

Credit Card
First Name	Last Name
Credit Card Number	Security Code
Expiration Month	Expiration Year

Signature*