Visiting Learners Application Form

Personal Information

Name:

Phone Number:

Contact Email:

Current Institution:

Location:

Rotation Information

Specialty:

Year of Training:

Preferred Start Date:

Preferred End Date:

Gender:

Traveling with Family (Yes / No):

Preferred Specialty For Rotation

Select Option 1 (mandatory):

Select Option 2:

Select Option 3:

Other (or subspecialty):

Organization Coordinating Your Rotation

Organization:

Referee Information

Name of 1st Referee:

Email Address of 1st Referee:

Name of 2nd Referee:

Email Address of 2nd Referee:

Short Answer Questions

1. What are your goals for participating in the Kijabe Elective Rotation?

2. What prior experience or exposure have you had working in low-resource settings?

3. How do you anticipate incorporating global health activities into your future plans?

4. How do you incorporate faith practice into your care, if applicable?

5. Do you have any questions or anything else you would like us to know?

Document Uploads

Passport Bio-data Page:

Certified Academic and Professional Certificate:

Curriculum Vitae (CV):

Recent Passport Size Colour Photo:

MD Certificate (Residents only):

Current practising licence (Residents only):

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