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 complete the challenge that you see below.

Medical Electives Africa - Information

Medical School Electives (Hospitals you are likely to work in)

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