Student elective application and scholarship application form

Before beginning, please read through the following instructions and conditions:

International electives are available to fourth year medical students who are in good academic standing. Third year students may receive permission on a case by case basis, and should discuss their elective plans with the Student Affairs office and Suzy Bentley (suzannebentley@gmail.com) prior to proceeding. In order to receive one week's credit, you must spend at least 40 hours during the week on this educational experience. You may not be under the direct supervision of any family members or individuals with whom you have a personal relationship.

Before submitting this form, ensure that you have:

Submitted the risk management form to Global Health office Annenberg 12-21. Click here to download the form.
Reviewed your health insurance policy and ensure that you have coverage for emergency services when out of the country.
Visited student health at least 3 months prior to departure, determined whether you need any vaccines, and whether you should bring along HIV post-exposure prophylaxis.
Considered obtaining a global phone (not mandatory, but strongly encouraged).
Emailed global.health@mssm.edu to obtain evacuation insurance from International SOS. Provide your birthdate, location you are traveling to, and dates of travel in the body of the email, with "SOS" in the header.

IF YOU ARE APPLYING FOR FUNDING through the Global Health Center, you must submit this elective form. Funding preference is given to students doing research or a public health project at a GHC partner site and traveling for longer periods of time. Language electives and pure clinical electives are not usually funded.

Name: *

Type your name.

Class: *

What is your graduating year?

Email: *

Your email address.

Life number: *

Please enter your life number. It should be printed on the back of your Mount Sinai ID card.

Emergency contact name: *

Please provide us with an emergency contact in the U.S. (like a parent or significant other)

Emergency contact phone number: *

Alternate phone number:

Global phone number:

In-country mentor/contact name: *

Please provide the name, title, department and institution of your mentor

In-country mentor/contact email:

In-country mentor telephone number: *

Preferred phone number: *

We may need to contact you with questions about your travel plans

Mount Sinai Supervisor:

Are you working with a supervisor at Mount Sinai? Please provide his or her name, title, and department

I have confirmed that my insurance provides emergency health coverage in my destination country: *

yes

This is mandatory prior to submitting this form, and in order to receive elective credit.

I have submitted letter of approval from in-country mentor to the Global Health office (Annenberg 12-21): *

yes

You may also send the approval letter/email electronically to global.health@mssm.edu. Please put your name and "Elective LOA" in the subject heading. Do not submit this form until you have the letter.

I have submitted my request for SOS insurance: *

yes

This is mandatory prior to submitting this form. Please email global.health@mssm.edu with the following: your name, DOB, dates of travel, country that you are traveling to. Please put your name and "Elective SOS" in the subject heading.

I have submitted the liability form to risk management: *

yes

This is mandatory prior to submitting this form. See top of form for instructions.

I have visited Student Health or my doctor to discuss vaccines and prophylactic medications: *

yes

I have an appointment

This is mandatory prior to submitting this form and in order to receive elective credit.

City or Region: *

Please provide the name of the city, or region (if you are traveling to a rural area)

Country: *

Dates: *

Dates of your elective.

Hours per week: *

How many hours per week will you be doing elective-related activities?

Number of weeks: *

How many weeks will your elective last?

Organization: *

Please provide the name of the organization(s) with whom you are working. Also provide the name of any medical schools or medical centers where you will be working.

Language: *

What is the primary language requirement for your elective? To what level of proficiency will you be expected to communicate in that language?

Budget:

Please provide an estimate of your costs for the elective, including travel and in-country costs (including tuition, if applicable). This will help other students who are considering doing this elective in the future, and will be taken into consideration for funding purposes.

Clinical responsibilities during elective: *

What clinical responsibilities will you have (if any) during the elective? Will you only observe or also have patient contact? Will you have adequate supervision?
In a separate paragraph, please describe what your goals are for the clinical component of this elective.

Elective title:

Enter title of elective being performed.

Other sources of funding (or state NONE, if you do not have other sources):

Please list other sources of funding that you have applied for (and the amount you have received, if known).

I am applying for the Mount Sinai Global Health Center scholarship.:

yes

Research Proposal:

If you are planning a research project during your elective time, please describe the project (including the background, methodology, scope of the project) and in a separate paragraph, your role specifically (whether you have designed this from start to finish, or if you will be collaborating with someone on the project)

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Student elective application and scholarship application form

Before beginning, please read through the following instructions and conditions:

Before submitting this form, ensure that you have: