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GLOBAL MEDICAL TRAINING at UCLA Trip Application 2011-2012 APPLICANT ELIGIBILITY Must be considered an active GMT member by meeting all membership requirements Must attend all mandatory trip meetings pertaining to trip of choice Must have completed and turned in trip application Must have completed trip payment Must have a passport by the time of intended trip Full Name (as shown on Passport) DOB: Sex M / F Passport Number: Major: Year in School : GMT Member Since: Have you applied for a GMT trip before? Y / N Quarter: Are you a past tripper: Y/N If yes, which trip did you attend? (quarter and destination) Trip Destination: Date of Trip Street Address Unit/Apartment # City State ZIP Code Home Phone Cell Phone Email Please Circle Pre-Medical Pre-Dental Pre-Pharmacy Pre-Nursing Pre-Veterinarian Undecided Other: One Spanish Fluency (Rate from 1-100%) Are you interested in a Deferred Payment Plan (DPP)? Y/N MEDICAL INFORMATION Medical Conditions/ Medications Emergency Contact 1 Full Name Phone Number Relation Emergency Contact 2 Full Name Phone Number Relation LEADERSHIP Are you interested in becoming a student leader on this trip? Yes / No Your responsibilities would include setting up the prevention pamphlets at clinics, helping GMT officers organize general members to take medications over to clinics before the trip date, and helping the doctors organize other trippers before dinner and in the mornings before clinic. Please write about significant leadership experience that demonstrates your abilities to succeed as a GMT tripper leader. Instructions for submission: Please submit a hardcopy of this application at our general meeting or to a GMT officer by Monday, January 23, 2012. Your application will be reviewed by GMT officers, and you will receive word of our final decision by Tuesday, January 31, 2012. In addition to this application, you must fill out the official online application at www.gmtonline.org once GMT at UCLA has sent you a confirmation email. Please check our website periodically for updates on the payment deadline.
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