Visiting Learners Application Form

Personal Information

Name:

Phone Number:

Contact Email:

Current Institution:

Location:

Specialty:

Year of Training:

Preferred Start Date:

Preferred End Date:

Gender:

Traveling with Family (Yes / No):

Select Option 1 (mandatory):

Select Option 2:

Select Option 3:

Other (or subspecialty):

Organization:

Name of 1st Referee:

Email Address of 1st Referee:

Name of 2nd Referee:

Email Address of 2nd Referee:

1. What are your goals for participating in the Kijabe Elective Rotation?

2. What prior experience or exposure have you had working in low-resource settings?

3. How do you anticipate incorporating global health activities into your future plans?

4. How do you incorporate faith practice into your care, if applicable?

5. Do you have any questions or anything else you would like us to know?

Police Clearance Certificate:

Passport Bio-data Page:

Certified Academic and Professional Certificate:

Curriculum Vitae (CV):

Recent Passport Size Colour Photo: