Application form
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FROM RESEARCH TO PRACTICE:
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Common Course: Methodological Issues in Health Research 2 weeks |
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Course 1: |
Course 2: |
| Reproductive
Medicine and Reproductive Biology |
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| 4 weeks | 4 weeks |
3 March 2003 – 11 April 2003
organised by
the Geneva Foundation for Medical Education and Research,
the UNDP/UNFPA/WHO/World Bank Special Programme for Research in Human Reproduction, Department of Reproductive Health and Research, Family and Community Health Cluster (WHO/RHR)
and
the WHO Noncommunicable Diseases and Mental Health Cluster (WHO/NMH)
in collaboration with
the Department of Health of the Canton of Geneva,
the Faculty of Medicine, Geneva University
and
the Geneva Medical Association
| COURSE CHOICE | |||||||||
| I, the undersigned wish to apply to participate in the Course in Methodological Issues in Health Research plus in one of the Courses below: | |||||||||
| Reproductive Medicine and Reproductive Biology | □Yes □No | ||||||||
| Chronic Disease | □Yes □No | ||||||||
| PERSONAL DATA | |||||||||
| Family name | |||||||||
| First names | |||||||||
| Maiden name | |||||||||
| Date and place of birth | |||||||||
| Nationality | |||||||||
| Position held at present (state your activities and responsabilities) | |||||||||
| Previous employments (last 4) | |||||||||
| Family status | |||||||||
| Number of children | |||||||||
| Address and telephone number during the studies in Geneva (if known) | |||||||||
| Father: Family name, first name date of birth, family status, nationality, exact place of residence | |||||||||
| Mother: Family name, first name date of birth, family status, nationality, exact place of residence | |||||||||
| Spouse: Family name, first name date of birth, family status, nationality, exact place of residence | |||||||||
| ADDRESS, TELEPHONE, FAX, E-MAIL | |||||||||
| Professional address | |||||||||
| Telephone number and Fax number with country and area codes | |||||||||
| Personal address | |||||||||
| Telephone number and Fax number with country and area codes | |||||||||
| E-mail address (If you don't have one, you could get one at no cost at Yahoo.com or Hotmail.com) | |||||||||
| LANGUAGE SKILLS | |||||||||
| Mother tongue | |||||||||
| Other languages | Reading | Writing | Speaking | ||||||
| Excellent | Good | Fair | Excellent |
Good |
Fair | Excellent |
Good |
Fair | |
| 1. | |||||||||
| 2. | |||||||||
| 3. | |||||||||
| 4. | |||||||||
| Please note that the lectures and exams will be held in English. Therefore, it is extremely important that your level of understanding, expressing yourself and writing in English is adequate. | |||||||||
| EDUCATION | |||||||||
| Secondary school studies | |||||||||
| Diploma of the secondary school | |||||||||
| Type of the diploma | |||||||||
| Country in which the diploma was obtained | |||||||||
| Year in which diploma was obtained | |||||||||
| School in which the diploma was delivered | |||||||||
| University studies | |||||||||
| University | |||||||||
| Country | |||||||||
| Faculty | |||||||||
| Successful examen and years of exams | |||||||||
| Obtained university title and exact field | |||||||||
| Academic certificates or diplomas and years when they were obtained | |||||||||
| COST AND FINANCING | |||||||||
| The cost to participate in the Course is approximately CHF 6,800. This amount includes lodging and the cost of living in Geneva for 6 weeks, registration and course organisation fee. Your travel cost is NOT included in this amount. | |||||||||
| If you are accepted to the Course, please indicate who will finance your participation in the Course | □Self: □Others (please give details): | ||||||||
| ACCOMMODATION | |||||||||
| If you are accepted to the Course, please indicate if you need student's accommodation in Geneva | □Yes □No | ||||||||
| ENCLOSURES | |||||||||
| Please attach the following
documents: 1. curriculum vitae with 2 photos; and a copy of your passport 2. a certified copy of the diploma in medicine and any additional diplomas 3. a letter of motivation stating clearly your interests and reasons for applying to the Course (1 A 4 page maximum) 4. an official attestation confirming your proficiency in the English language 5. two letters of reference, preferably one form your current employer 6. if possible, please submit the following document: an introduction by your Head of Department stating your role and future involvement in your country's National Reproductive Health Programme/ Programme for Chronic Disease |
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| Place and date | |||||||||
| Signature | |||||||||
Please send your application to the following address:
Postgraduate Training in Reproductive Health/Chronic Disease
Geneva Foundation for Medical Education and Research
3, Route de Florissant
Geneva
Switzerland
Edited by Aldo Campana,