Application For Medical Shadowing in Thailand Summer 2024

Applicant Name *

First

Last

Gender: How do you identify? *

Please understand participation in this program involves your rooming with other participants so we need to have an accurate understanding of your gender identity.

Self Describe your gender identify.

Birth Date

Applicant Email *

Phone Number of Applicant

Primary Address

Address Line 1

Address Line 2

City

State

Zip Code

Alternate Address

Address Line 1

Address Line 2

City

State

Zip Code

What airport would you be flying out of if participating in our program?

Write a short essay describing your career goals and why you wish to take this course. *

What is your current status as a student?

Current undergraduate student
Completed undergraduate degree and not currently a student
Current graduate student

What is your course of study? *

Describe course of study if you answered "other" above

Name of your current educational institution

Name of institution you graduated from.

Please upload a copy of your most recent university transcripts.

Click or drag a file to this area to upload.

What is your country of citizenship? *

Do you hold a passport that is valid through December 5, 2024? *

Yes
No

You do not need a valid passport to be accepted to this course. However, you must have a valid passport before the departure date for the program, If you do not have one now apply for a passport as soon as possible.

Passport Number

Date Passport Issued

Expiration Date of Passport

Please upload a scanned copy of the photo page of your passport.

Click or drag a file to this area to upload.

Have you ever traveled outside the US? *

Yes
No

Please list countries you have traveled to and describe the purpose of your travel. *

Name of Emergency Contact #1 *

First

Last

Relationship to Applicant *

Mother, father, spouse etc.?

Phone Number of Emergency Contact 1

Email Address of Emergency Contact #1 *

Address of Emergency Contact #1

Address Line 1

Address Line 2

City

State

Zip Code

Name of Emergency Contact #2 *

First

Last

Relationship to Applicant *

Mother, father, spouse etc.?

Phone Number of Emergency Contact 2

Email Address of Emergency Contact #2 *

Address of Emergency Contact #2

Address Line 1

Address Line 2

City

State

Zip Code

List any health issues (psychological or physical) you have. If you have none please write "None." *

This information will be used to assure your health and safety during our time abroad and will not be shared with anyone except our group leaders on a need to know basis.

List any prescription medications you may need to take while abroad. Write "None" if you have none. *

Please provide information on your level of physical activity. These questions are not used as criteria for acceptance into the program but are asked to permit us make decisions about course activities and excursions. CHECK ALL BOXES THAT APPLY.

I am capable of riding a bicycle for distances of a mile or two.
I am not capable of riding a bicycle.
I am capable of participating in a supervised hike in the wilderness over rough terrain.
I am not capable of hiking in the wilderness
I am a strong swimmer
I can swim but am not a strong swimmer
I cannot swim
I have experience with canoeing and kayaking
I have no boating experience

Describe any assistance or accommodations you will require to participate in this program. Include dietary restrictions. If none write "none." *

List any allergies you have to foods or other substances. Write "none" if none. *

Describe any dietary preferences you have (example: vegetarian).

How did you hear about this program? *