Global Health Year-Out Program Student Application Form

Name Name First Last
Email
Year

Year MS1 MS2 MS3 MS4

Eligible students will have completed their core clinical clerkships.
Are you in a dual degree program?

Are you in a dual degree program? Yes No
If yes, which program?
Are you in a certificate program?

Are you in a certificate program? Yes No
If yes, which certificate?
When do you plan to do your Year-out?
Brief description of research interest:
Intended clinical specialty/specialties you are considering:
Brief Description of former research experience:
Relevant Global Health Coursework
Countries/Regions of Interest:
Have you consulted with Dr Mark Neuman about taking a year out?

Have you consulted with Dr Mark Neuman about taking a year out? Yes No

It is important to discuss a global year out with Dr. Neuman prior to completing this form.
Sign-off from Associate Dean of Students Success and Professional Development (upload document or email from Dr. Jennifer Kogan confirming your ability to take year out)

Attach Files

Interest Level
Interest Level	Highly Likely	Moderately Interested	Interested, but need more information
How interested are you in pursuing this opportunity?	How interested are you in pursuing this opportunity?Highly Likely	How interested are you in pursuing this opportunity?Moderately Interested	How interested are you in pursuing this opportunity?Interested, but need more information