Medical Electives Booking Form

Please only use this form to book a medical elective. For general enquiries please use the "Contact Us" page button on the left.

All students wishing to participate in our programs must submit a completed Medical Electives Booking Form.

In order to provide students with a worthwhile experience, we limit the number of students on service. You are therefore encouraged to submit your application as early as possible, to allow time to process your request and ensure acceptance of your choice dates.

Upon completion of the application, and acceptance into the elective program, a letter of acceptance will be emailed to you and you can then make flight arrangements and take any vaccinations you may need.

Medical Electives Booking Form

Please note that all fields followed by an asterisk must be filled in.
First Name*
Last Name*
E-Mail Address*
Street Address*
City*
State/Prov
Zip/Postal Code*
Country*
Home Phone*
Business Phone
Gender*
Birthdate (mm-dd-yyyy) *
Nationality *
University*
Emergency contact (Name, Telephone & Complete Address)*
Education and Experience (Please copy & paste your CV/Resume here.)*
Health conditions (e.g. allergies, disabilities etc)*
Program *
Medicine Electives
Nursing & Midwifery Electives
Dentistry Electives
Physiotherapy Electives
Are you travelling with a friend?*
Yes
No
Name of friend/friends if applicable
Destination Country*
Kenya,
Tanzania
Zanzibar
Malawi
Ethiopia
Rwanda
Ghana
Senegal
Zambia
Uganda
South Africa
Enter any other preferences/requirements here.
I wish to join other students for a safari. (Several students join in for a 4 day safari).*
Yes
No
How long is your medical elective period? *
2 weeks
4 weeks
6 weeks
8 weeks
10 weeks
12 weeks
When do you plan to arrive and depart. State the month, date and year.*
Indicate here if you require any further information.
How did you hear about us?
Any other comments?

Please enter the word that you see below.

  



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