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					Application for the RESIDENCY ROTATIONS
                                                                                                   Send application materials and
             MEDICAL EDUCATION COOPERATION                                                     the appropriate application fee to:
                                                                                                                            MEDICC
             With CUBA                                                                      Emory University School of Nursing Bldg.
                                                                                                      1520 Clifton Road, Room 438
                                                                                                            Atlanta, GA 30322-4207
                          Dates of MEDICC Rotation you are applying for:

Passport Information                                Please print clearly

1.   Please read passport carefully while completing this section. Complete name and dates as appear on passport.


     Last Name                                      First Name                                    Middle Name (if on passport)

2.   Gender: O Male     O Female        3. Birth date:                                 4. Place of birth:
                                                         Month / Day / Year                                   State/province, country

5.   Passport Number:                                        6. Date of issue:
                                                                                    Month     /    Day /     Year

7.   Place of issue:                                         8. Date of expiration:
                                                                                        Month       /   Day /       Year

Personal Information

9.
     Email Address Please provide your complete email address, making sure to clearly indicate capital letters and numbers.


10. Current Mailing Address


     City                                           State                                                   Zip Code

                                                             /
11. Home Telephone Number                                    /                   Daytime Telephone Number


12. Permanent Mailing Address (if different from current address)


13. Ethnic Status: Choose one that best describes you. Your response is voluntary, and will help us assess diversity in MEDICC.
     O Black or African American                            O Hispanic or Latino
     O Native American/Alaska Native                        O Asian/Pacific Islander
     O White/Caucasian                                      O other




      EMERGENCY CONTACT INFORMATION

      Contact Name:                                                 Relation to you:

      Phone(s):                                                     Email:

      Address:
Current Residency Informations                                 Please print clearly

14. I am currently pursuing a residency in (specialty/field): _______________________________________________________


     _______________________________________________________________________________________________________
15. Name of School/hospital/institution affiliated with:

16. Name of Medical School received MD Degree from

17. Additional post-graduate training: Institution / Program / Degree

18. Name of Undergraduate University



Spanish Proficiency
Note: All MEDICC rotations are conducted in Spanish only.

19. Please indicate your level of Spanish:
    _____ Native Speaker
    _____ Fluent / Advanced


Rotation Dates Request
20. Total time I wish to spend in Cuba (minimum of 4 weeks): _______________________________________________________________

21. Range of dates available (list two alternative dates): _____________________________________________________________________

     ____________________________________          (request must be received by MEDICC four to five months prior to rotation start date)

Rotation / Elective Program Focus

22. Indicate preferences in order – 1st choice, 2nd choice, etc.


_______           Clinical Overview of the Cuban Public Health Care System (including community-based systems of care / The
Family Doctor Program / Primary Care / visits to secondary and tertiary care institutions / epidemiological monitoring systems, etc.)
with particular enphasis on/in:              ___ Family Medicine                          ___ Geriatric / Gerontology
                                             ___ Internal Medicine                        ___ Women’s Health
                                             ___ Pediatrics                               ___ Oncology


_______           The Integration of Natural and Traditional (“Alternative”) Medicine into the Cuban Health Care System.


_______           HIV/AIDS Prevention and Treatment


_______           Mental Health Care in Cuba:         ___ Child and Adolescent            ___ Adult          ___ Both/General
_______            Other (if you have another /different specialty area of interest that does not all into one of the above, please list it
below, having selected at least one of the above, and MEDICC will work with you to develop a program that both meets your
particular interests/needs and at the same time is workable in Cuba).




Medical Information                                      Please print clearly

23. Are you currently taking any prescription medications? yes___ no____
24. Do you have any special dietary needs? yes_____ no_____
      If yes, please specify:
25. Do you have any allergies to food or medicine? yes____ no_____
      If yes, please specify:
26. Are you currently under the care of a physician for a chronic medical condition? yes____ no_______
      If yes, please specify:


Signature
27. I certify that all the information in this application is true and accurate. I understand that withholding information or making false
    statements will disqualify me from participating in the MEDICC program.

      __________________________________                                    ___________
      Applicant signature                                                   Date

Essay Requirement

28.       Please write a brief statement on your expectations for the Cuba rotation, and how it will contribute to your training
          and future plans.

Check List Do you have all of these items?
1.    Completed application form (including essay) TWO COPIES
2.    Signed and dated Participant Agreement TWO COPIES
3.    Photocopy of Passport picture/signature page TWO COPIES
4.    Curriculum Vitae TWO COPIES
5.    Non-refundable APPLICATION FEE OF $75 (make check or money order payable to “MEDICC”)


Mailing Instructions
Please mail all application materials to the address below before the application deadline:
MEDICC
Emory University School of Nursing Bldg.
1520 Clifton Road, Room 438
Atlanta, GA 30322-4207
                                                                                           Please return signed agreement with
                                                                                               application materials directly to:
            MEDICAL EDUCATION COOPERATION                                                                                MEDICC
                                                                                         Emory University School of Nursing Bldg.
            With CUBA                                                                              1520 Clifton Road, Room 438
                                                                                                         Atlanta, GA 30322-4207




Participant Agreement                                      Please read carefully

I PROMISE THAT I SHALL NOT TREAT OR DIAGNOSE A PATIENT WITHOUT THE SUPERVISION OF THE
PRECEPTOR OR PROFESSOR ASSIGNED TO ME IN CUBA.

1. I have carefully read the MEDICC brochure and application forms. I understand that their terms and conditions are
incorporated into this agreement.
2. Should I become ill or incapacitated, I agree to allow MEDICC/the Cuban Ministry of Public Health (MINSAP) to take all
actions necessary to procure appropriate medical services, including if need be transportation to my home or hospitalization at
my own expense.
3. I agree to conduct myself professionally during the program, to cooperate with MEDICC staff and my fellow participants.
This includes commitment to full attendance at Monday-Friday course activities. I realize that misconduct on my part may
result in expulsion from the MEDICC program without refund of fees; and reiterated unjustified absences from course activities
will be cause for an unsatisfactory academic evaluation.
4. I understand that MEDICC, its staff or representatives are not responsible for circumstances beyond their control
(including but not limited to natural disasters or phenomena, sickness, government regulations) or for actions on the part of
persons not under MEDICC management (such as, but not limited to, travel agencies, airlines, other governmental bodies or
private corporations). I agree to exempt MEDICC and its staff from all claims arising out of such actions.
5. I agree to exempt MEDICC and its staff from any claims of injury while a participant in the MEDICC program.
6. I agree that MEDICC may modify the course program as necessary (including program dates within one week of original
dates, professional activities and work/study assignments). I agree that such changes are not grounds for withdrawal from the
program or for a refund.
7. I realize that it is my responsibility to complete all forms, make all travel arrangements, and submit all payments by the
deadlines indicated. I agree to travel to and from Cuba on the first and last days stipulated for my elective: should this be
impossible and MEDICC decides to accept my application, I agree to pay airport transfers to and from the medical school where
the elective is offered, and for any necessary accommodations in Havana before or after the stipulated travel dates.
8. I agree to submit the required non-refundable deposit to MEDICC in the USA, and to pay the full balance upon arrival
in Cuba. Should I return home before the elective is completed, I understand that a refund will ONLY be granted in case of
emergency (e.g. student illness, family death or illness, or “academic emergency” demanding an urgent return that cannot be
postponed). In case of emergency, I understand that the following refund policy will apply: if the student returns home before
one third of the elective period is over, then she/he will receive a 50% refund of payments made in Cuba (not to be applied to
the non-refundable deposit). After that point, no refunds will be given.
9. I recognize that it is my responsibility to obtain a valid passport, and to submit two copies of the passport photo page
with my application. I agree to furnish whatever information may be requested by MEDICC and its staff in order to complete
application for my U.S. Treasury travel license and my Cuban visa.
10. I agree to abide by pertinent U.S. and Cuban laws, including but not limited to U.S. Treasury Department regulations
governing licensed travel to Cuba and stipulating that U.S. nationals may not spend over $166 per day in Havana and $125 in
the provinces.
11. I understand that my U.S. Treasury travel license and my Cuban visa are valid only as long as I am participating in
the MEDICC program and that any attempt by me to use these documents for other purposes is in violation of the laws of both
governments. I exempt MEDICC, the Cuban Public Health Ministry and their representatives from any responsibility once I
have completed or left the MEDICC program.
12. I exempt MEDICC and its representatives from responsibility for any financial obligation I incur personally, as well
as for any damage or injury that I may cause to person or property while I am a participant in the MEDICC program.



Name                                                       Signature                                    Date

				
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