University of New Mexico Pre-Health Organization

University of New Mexico Pre-Health Organization

www.unm.edu/~imd

Application Form

Due September 7, 2007

Required information:

1.  Two letters of recommendation

2.  Copy of most recent unofficial transcript

3.  Resume

4.  Completed Application Form, including signature on Waiver of Liability.

NAME ______SEX: ____

ADDRESS ______

______

PHONE: (h) ______(w) ______

EMAIL: ______

DATE OF BIRTH: ______

BIRTHPLACE: ______

CITIZENSHIP: ______

PASSPORT NUMBER: ______

SCHOOL ATTENDING IN 2007-2008 ______

YEARS COMPLETED_____ INTENDED MAJOR______

DEGREES EARNED______

IN CASE OF EMERGENCY, PLEASE NOTIFY:

NAME: ______

RELATIONSHIP: ______

ADDRESS:______

______

PHONE: (h)______; (w) ______

9. Please assess your physical condition and indicate any disabilities, allergies, etc., and any medications you are currently taking and what, if any, medical conditions you have.

______

10. What is your level of Spanish comprehension/verbal skills?

______

The following questions should be answered on a separate sheet of paper, typed, and handed in with the application. The responses should not exceed 600words each.

11. Will you be able to participate in presentations, fund-raising, and other support work for APRODEHNI prior to the delegation? What fund-raising ideas can you bring to IMD (please give concrete ideas/examples/events)?

12. What is your understanding of the current situation in El Salvador? What is your understanding of the roots of the conflict in this country?

13. How do you deal with tension and stress? How do you respond when confronted by injustices and sharp levels of poverty?

14. Why do you want to participate in APRODENHI’s medical delegation to El Salvador? What special talents or skills will you bring to the delegation?

15. What do you see as your role as a medical delegate in El Salvador? What do you wish to accomplish throughout the experience?

16. Please suggest at least three (3) projects that you would be interested in developing and proposing to APRODENHI for possible projects in El Salvador (presentations, outreach projects, education, etc.).

WAIVER OF LIABILITY AND ASSUMPTION OF RISK

I, ______, voluntarily join a delegation jointly sponsored by APRODEHNI. I am participating in this delegation because I want to gain a better understanding of the situation in El Salvador and to support human rights and democracy for the people of El Salvador. I recognize and assume the risks of travel to and from and within El Salvador. On behalf of myself, my family, heirs, representatives, executors, administrators and all other persons making any claim by reason of relationship to me, I hereby release APRODEHNI and any of their affiliates, subdivisions, officers,

directors, employees, advisors, agents and representatives from any claims, damages, costs including attorneys' fees, or other liabilities resulting from personal injury, property damage, or other losses of any kind in any way connected with participation in this delegation. I have carefully reviewed this form in its entirety and by signing below agree to its terms with full understanding of its meaning and effect. Intending to be legally bound, I am signing this Waiver of Liability and Assumption of Risk in consideration of my participation in this delegation. I have also read the delegation security guidelines. I understand and agree to abide by them for the duration of the delegation.

Signature: ______Date: ______

International Medical Delegation: El Salvador

Student Activities Center, Box 153 MSCO3 2210, 1 University of New Mexico, Albuquerque, NM 87131-0001