ghtl application form 2016

8/19/2019 GHTL Application Form 2016

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Global Health True Leaders 2016

Application Form

DEADLINE: MAY 8, 2016

SECTION 1: REGISTRATION FORM

Participant information:

First Name:_____________________ Middle: _____________________ Last:____________________

Nick Name:___________________________________________

Please thick one: Undergraduate Student Health Practitioner Graduate Student

Please fill it if you are an undergraduate student

Semester (thick one): 5th 6th 7th 8th

Current University:________________________________________________________

Faculty: _________________________________________________________________

University address: ________________________________________________________

Expected graduation date: ___________________ Current GPA: ___________________

Please fill it if you are a health practitioner or graduate student

Current Company/Faculty-University:_________________________________________________

Company/Faculty-University address: _________________________________________________

Study Background: ________________________________________________________________

Graduated date: _________________________________ Previous/Current GPA: _____________

Birth Date: Date_________ Month_________________________ Year______________

Current Address: ______________________________________________________________________

City:______________________________ Province:_________________________________________

Country:__________________________________ Zip code:______ ___________________

Phone Number: Home________________________ Mobile______________________________

Email Address:_____________________________________________________________________

Citizenship: ___________________________________________


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Parent/ Guardian Information

Parent Name:______________________________________________________ ____________________

Parent Phone Number: Home__________________________ Mobile__________________________

Parent Email Address: _____________________________________________________________________

Parent Street Address (if different from above):_______________________________________________

Emergency Contact: Name__________________________ Phone Number___________________________

SECTION 2: HEALTH INFORMATION

Physical Limitations:_____________________________________________________________________

Dietary restrictions:_____________________________________________________________________

Please list any known allergies:____________________________________________________________

Please mention your illness record:_________________________________________________________

_____________________________________________________________________________________

Please list any other health concerns you may have:___________________________________________

SECTION 3: EDUCATION

List the college you have attended starting with the most recent:

CollegeYour Previous or Current College

MajorYour Previous or Current Major

Graduated YearYear that You Graduated

Expecting Graduate YearYear that You Expecting to Graduate

SECTION 4: Current Business and Employment History (if applicable)

Company: From (MM/YY):

Address: City/Zip:

Phone: Email:


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Application Form


Fax: Website:

Briefly describe your position and responsibilities:

SECTION 5: ORGANIZATIONAL EXPERIENCES

Please describe any organizational experience that you have been involved, including: working experience,

internship experience, volunteer organizations, community associations, or similar:

Organisation Year Position Held Description of Involvement


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SECTION 6: SCHOLARSHIP AND AWARDS

Please detail any scholarships, academic awards, bursaries, prizes you have obtained.


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SECTION 7: TRAINING AND WORKSHOP

Please indicate any training and workshops you have attended in last 3 years.

Name of Training or Workshop Year

SECTION 8: LANGUAGES

How would you describe your English and/or other Languages skills? (1=poor; 5=excellent)

Language Years studied Speaking (1-5) Reading (1-5) Writing (1-5)

English


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Application Form


SECTION 9: SHORT ANSWER QUESTIONS

Please answer the following questions to the best of your ability.

1. Please describe your motivation to participate and the experience that you hope to gain in Global

Health True Leaders. (in 1 paragraph)

2. Please describe your personal definition of Leadership, the qualities to be a good leader (please give an

example), and your experience in leadership. (in 1-2 paragraph)

3. Please describe your future plan in five years. (in 1 paragraph)


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Scholarship Form


Please Note:

1. This scholarship is awarded to Global Health True Leaders participants in order to attending the

training. Please complete the information in application form and email to the [email protected].

If selected, you will receive a confirmation letter.

2. More than 150 scholarships are available for Global Health True Leaders participants.

3. The detail of scholarship package below.

Scholarship Scholarship is include

Gold

Accommodation, Training fee, Field Work fee, Field Leadership Fee, City Tour fee,

Training Kit, Training Materials, Meals, and Gala Dinner

Platinum Transportation by airplane, Accommodation, Training fee, Field Work fee, Field

Leadership Fee, City Tour fee, Training Kit, Training Materials, Meals, and Gala Dinner

Please answer the questions

Name of Applicants: ____________________________________________________________________

Occupation: ________________________________ Study background: _____________________

Company/Faculty: __________________________ GPA: ___________

Please indicate the amount you are able to pay:___________________

Important:

It is your responsibility as applicant to submit the PDF which including Application form, Health Certificate,

English Proficiency, Police Clearance Report, Identity Card, and Photo in one file (in format: GHTL 2016_Your

Name_Your Institutions_Your Current Domicile.pdf). If selected, we will publish the announcement of Global

Health True Leaders candidates on www.indohun.org on May 15, 2016 and you will receive a confirmation

letter. Please fill the confirmation letter and send it to INDOHUN email due to July 1, 2016. You will be an

official participant of Global Health True Leaders once you received the official invitation letter.

mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.indohun.org/http://www.indohun.org/http://www.indohun.org/http://www.indohun.org/mailto:[email protected]


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REQUIREMENTS AND RULES


1. There are 6 required files that you must be submitted to register yourself to be Global

Health True Leader participant.

Application form

There are 8 sections included. Each section contains questions which must be completed

with straightforward and factual answer. These include those that enquire about your

personal details, interests, educational background, and other related to GHTL. More than

150 scholarship will be awarded to several qualified applicant. Scholarship will cover all

the training costs, including accommodation and transportation fees.

Health certificate

Health certificate is a result of medical examination to describe condition a person has,

such as allergic or sickness. It can be obtained in hospital or health center.

English proficiencyIt can be a valid TOEFL, IELTS, TOEIC score, least is a TOEFL prediction score.

Police clearance report

An official document issued by the police or government agency of a country as a result

of a background check to enumerate any criminal records that the applicant may have. In

Indonesia, it is known as SKCK (Surat Keterangan Catatan Kepolisian). You have to submit

the valid one.

Identity card

The identity card can be residential identity card, student identity card, driver license, or

passport.

Photo

Your photo must be a half body formal photo with white background and clearly seen face.The photo size is 4x6.

2. All the required files must be completed and submitted to [email protected] with subject

“[GHTL 2016 Application] Name_Domicile(province)” no more than May 8, 2016.

Uncompleted files and submission after the deadline will not be proceed. All files must be

merged into one file (PDF) with the format name:

3. We will announce the selected applicant on website www.indohun.org on May 15, 2016

and send the confirmation letter to all candidates. Please complete the confirmation letter

and send it back to [email protected] due to July 1, 2016.

4. You are officially being a participant once you received the official invitation letter from

INDOHUN.

5. Global Health True Leader participants will be divided into three regions (Padang,

Kupang, Bali) by INDOHUN’s team through some considerations. The placement decision

is absolute.
https://en.wikipedia.org/wiki/Policehttps://en.wikipedia.org/wiki/Background_checkmailto:[email protected]:[email protected]:[email protected]://www.indohun.org/http://www.indohun.org/http://www.indohun.org/mailto:[email protected]:[email protected]:[email protected]:[email protected]://www.indohun.org/mailto:[email protected]://en.wikipedia.org/wiki/Background_checkhttps://en.wikipedia.org/wiki/Police

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