Application Form – LACONSTANCE CENTER FOR GLOBAL HEALTH

Name: *

First

Last

Title

Dr / Mr / Ms / Mrs / Other

Date of Birth:

Nationality of Passport:

Permanent Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone:

Email *

Temporary Mailing Address:

Address Line 1

Address Line 2

City

State

Zip Code

Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Checkboxes

Undergraduate
Postgraduate
Medical School

Area Of Study:

Year Level:

Institution of Study:

Position:

Institution:

Country Location:

What date will you arrive in Ghana?

Airline:

Departure Airport:

How long do you plan to Stay in Ghana?

What date are you leaving Ghana?

What are your specific areas of interest?

Will your activity involve Research?

Yes
No

If Yes What is your Research Topic:

(Please note: If your activity involves Research, an Institutional IRB must be approved both here and in Ghana. Must be submitted for the Ghana approval 6 months before departure)

Do you expect your activity to involve hands on independent Clinical Work?

Yes:
No:

(If yes, please note that an Appropriate Temporary License may have to be applied for you based on you level of study with an applicable fee)

Do you have any special needs ?

Yes:
No:

If Yes please specify

Attach File:

Click or drag a file to this area to upload.

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