Medical Elective Form

SIM / EHA Medical Elective application Form

If you're considering a medical elective with SIM, please complete the form below. Include as much detail as you can.

We regret that we can only accept enquiries from residents of the UK and Europe. If you wish to enquire from anywhere else, please visit your nearest office website — go to Overseas Offices for a list of addresses and websites.

SECTION ONE - Information required by Hospitals overseas:

PERSONAL DETAILS

Name (Exactly as it appears on your passport) *

Gender *

Date of birth *

Marital Status *

Email address *

Present address *

Line 1 *
Line 2
Town *
County
Postcode *
Country

Daytime phone number *

Evening phone number

Mobile Phone number

At the above address until

Permanent address (if different from above)

Line 1
Line 2
Town
County
Postcode
Country

PLACEMENT PREFERENCE

Prefered location

1st choice

2nd choice

3rd choice

While we will endeavour to place you at the hospital of your choice this may not be possible. If that is the case we will let you know of other possible options for you to consider.

Do you have any friends you wish to be placed with? If so please list their name(s)

Dates available (as accurately as possible) *

Length of assignment (in weeks) *

What professional experience do you hope to gain from your placement?

YOUR FAITH

Church Affiliation

Christian activities (missions, camps, church involvement etc)

Reason for seeking appointment in a Chritian hospital in this location?

How would explain your relationship with Christ to someone from a non-Christian background?

OTHER INFORMATION

Previous experience (if any) overseas

Condition of health (please include details of any medication you are currently taking)

What financial arrangements will you make to cover the cost of your placement?

Have you any skills (apart from medical) to offer? eg musical, teaching

Languages known apart from English? Please indicate level of lfuency

Any other hopes/expectations for this placement?

Are there any special requirements of your elective?

MEDICAL TRAINING

Medical School/University

Expected graduation date

Please detail practical experience you have completed as a part of your course.

Practical subjects to be completed before elective placement

Any other information related to this application?

Date submitted *

Thank you

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Medical Elective Form