Zambian Program in 2018 – Medical Camp Registration Page Zambian Program Hospital shadowing program for USA and Canadian students interested in pursuing a career in healthcare/medicine - to take place in Zambia - June 2018 Name* First Last Given and Family Names of Applicant (Student)Age*Age as on January 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 AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarrussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Your official physical address pleaseAcademic institution (college/university) name:*Academic institution (college/university) nameDietary preferencesNo specific preferenceVegetarian/veganKosherHalalPlease 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. This iframe contains the logic required to handle Ajax powered Gravity Forms.