International & Health Equity Learning (IHEL) Application Form 4th Year - Partner Places

Fields denoted by an asterisk (*) are required.

Personal Information
Name Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Citizenship
Program Location

Program Location London Windsor
Student Number
Western ID
Schulich Email Address
Local Phone Number Local Phone Number - ### - ### ####
Where did you hear about the IHEL Program?
Elective Information
Placement Site
Preferred Dates (start/end)

Please review the travel dates for each placement site above before entering a preferred start/ end date.
Elective Start Date Elective Start Date / MM / DD YYYY
Elective End Date Elective End Date / MM / DD YYYY
Clinical Area of Study (please note three choices)
Health Information:
HIV Post Exposure Prophylasis (PEP) Protocol available for Host Site:

HIV Post Exposure Prophylasis (PEP) Protocol available for Host Site: YES, the host site has a protocol for HIV PEP (submit as PDG with this form below) NO, I am unaware of an HIV PEP Protocol for this site.
Upload link for PEP Form (PDF ONLY)

Attach Files
Have you travelled internationally?

Have you travelled internationally? Yes No
If so, where and in what capacity? (please provide a detailed answer outlining your previous experiences travelling, including dates and locations)
What specific factors attract you to this university, and how do you envision this opportunity contributing to your growth as a student? (250 words minimum)
Minimum of 250 words required. Currently Entered: 0 words.
Please outline how you plan to be a good representative for Schulich and Western during your time away. (250 words minimum)
Minimum of 250 words required. Currently Entered: 0 words.
Please identify at least three learning objectives you have identified for your time during the IHEL experience. Please also explain how these personalized learning objectives relate to your current studies (200 words minimum).
Minimum of 200 words required. Currently Entered: 0 words.
How does this opportunity align with your career aspirations, and in what ways will it support the realization of your long-term goals? (250 words minimum)
Minimum of 250 words required. Currently Entered: 0 words.
What distinctive qualities, experiences, or achievements set you apart as an exceptional candidate for this opportunity? (250 words minimum)
Minimum of 250 words required. Currently Entered: 0 words.
Please upload a letter of good academic standing that is no older than 2 months. This can be obtained from the UME Office (undergraduate.medicine@schulich.uwo.ca).

Attach Files
Please note:

Embarking on an international exchange is a unique privilege, offering unparalleled academic and personal growth. Please note that academic issues before your scheduled exchange may jeopardize your participation. Ensure eligibility by addressing concerns promptly through academic support services.

Students with a Professionalism flag of Level 2 or higher on their academic record will not be considered. Please review the Professionalism flow chart for further detail.

If you have any questions regarding your eligibility, please contact internationalization@schulich.uwo.ca
Declaration

Declaration Yes I understand

International & Health Equity Learning (IHEL) Application Form 4th Year - Partner Places

International & Health Equity Learning (IHEL) Application Form 4th Year - Partner Places

Personal Information

Elective Information

Preferred Dates (start/end)

Health Information:

Please note: