Registration Deadlines

Registration ends April 15, 2017

Minimum Deposit: 30% payable after receipt of the acceptance to the program notification.

Clinical Skills Program Cost (5 days): $1500.00 (All inclusive - tuition, accommodation, meals and various medical Kits)

Student's Information

First name *

Last name *

Size (for a set of Apprentice Doctor® surgical scrubs)
Extra SmallSmallMediumLargeXLXXLXXXL

Gender
MaleFemale

Age
14151617181920212223>23

Student's Academic Level (High School Gr 10/11/12 or Pre-Med Year 1/2/3 or 4) *

Student's Email Address *

Student's Contact Number *

Mailing address *

Address Line 2

City
*

State / Province / Region
*

ZIP / Postal code
*

Country *
Select a CountryAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe

Parent/Guardian's Name
First name *

Last name *

Parent's Guardian's Contact Number *

Parent/Guardian's Email Address *

Alternative Contact Name (Optional)
First name

Last name

Alternative Contact Number (Optional)

Preferred e-mail address for all camp communication:
Student EmailParent/Guardian EmailAlternate Email

Name of School / College / University (max. 70 characters)

Contact Person at School / College / University (max. 35 characters)

Contact Person's Phone No

Medical information:

Name of Physician *

Phone Number *

List any allergies/surgeries/illnesses (indicate "NIL" if none) - max. 500 characters *

List of chronic medication and instructions for how it is to be taken (max. 500 characters) *

Please note:

1. Student will need a copy of the prescription or a letter from attending doctor for travel purposes

2. It is the parent's responsibility to ensure that the student is well informed about the specifics of the medication and prescription

3. It will be the student's responsibility to take his/her medication as prescribed

Name of person other than parent in case of emergency
First name *

Last name *

Phone Number *

Relationship (e.g. aunt, friend, etc.) *

Comments

Students: In order to ensure a high level of excellence at the camp, kindly write a letter addressed to Dr Anton Scheepers. Include information about your academic level and most recent grades, relevant experience and training and also telling us a bit about yourself, your future plans and why you would like to attend the camp.
max. 2500 characters

The Apprentice Doctor® Camp Selection Committee will consider your application and successful applicants will be notified per e-mail. You will also receive a " Welcome to Camp phone call."

Thank you! We look forward to seeing you at The Apprentice Doctor summer medical camp.

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