South African Program 2018 Registration Form South African Program Hospital shadowing program for USA and Canadian students interested in pursuing a career in healthcare/medicine - to take place in South Africa - May to June 2018 Name* First Last Given and Family Names of Applicant (Student)Age:*Age as on January 1, 2018Gender*MaleFemaleGenderAcademic Level:*Premed 1Premed 2Premed 3Premed 4Academic Level as in January 2018Scrub sizes*XSSMLXLXXLKindly let us have the size of scrubs that you wear (if unsure - rather choose slightly bigger).Email address student:* Enter Email Confirm Email The student's/applicant's email addressParent's guardian's Email address:* Enter Email Confirm Email Email address of a parent/family member taking responsibility to assist with arrangements for the program.Student's mobile phone number:*Student's mobile phone number:Parent's/guardian's phone number:*Parent's/guardian's phone number - or a responsible adult family member/friend...Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Your official physical address pleaseAcademic institution (college/university) name:*Academic institution (college/university) nameDiet preferenceNo specific preferenceVegetarian/veganHalalCosherPlease comment on food allergies at "Other" - give details.Medical information:*Kindly let us have information regarding allergies, medical conditions/problems and chronic medication - or anything else that you want to bring under our attention in this regard. Write "None" if no problems.Contact person in case of emergency:Phone number for person to contact in case of emergencies:*Phone number for person to contact in case of emergencies:Application letter:*Write an application letter to Dr Anton Scheepers with information about yourself (academics, achievements, etc.), your goals and dreams and why you believe you should be accepted into the Apprentice Doctor Program. (Maximum 3000 characters).Letter of recommendation* Drop files here or The letter/s of recommendation should be a one-pager from e.g. a professor who knows you well, and should focus on character (ability to work in a diverse group, follow instructions and work ethics etc.). Academic performance is not a requirement.Captcha This iframe contains the logic required to handle Ajax powered Gravity Forms.
