GLOBAL MEDICAL TRAININGat UCLATrip Application 2011-2012 by tyC9OW

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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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