4th Years - Self-Organized

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
Which year will you be in when you plan to travel?

Which year will you be in when you plan to travel? First Year Second Year Fourth Year
Student Number
Western ID
Schulich Email Address
Local Phone Number Local Phone Number - ### - ### ####
Where did you hear about the IHEL Program?
Elective Information
Partner Site:
Host Site Information:
Site Name
Site Address Site Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Site Supervisor Name Site Supervisor Name First Last
Site Supervisor Position/Title
Email Address of Host Supervisor
Academic Information:

All applications are required to be submitted at least 90 days prior to travel and must be approved by both the UME and the Schulich Internationalization Office
Elective Start Date Elective Start Date / MM / DD YYYY
Elective End Date Elective End Date / MM / DD YYYY
Affiliated Host University
Clinical Area of Study (please note three choices)
Type of Clinical Setting (Check all that apply)

Type of Clinical Setting (Check all that apply) Rural Urban Hospital Clinic Home Visits Mobile Clinics TB Patients HIV/AIDS Patients
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 1st/2nd/4th Years - Self-Organized

International & Health Equity Learning (IHEL) Application Form 1st/2nd/4th Years - Self-Organized

Personal Information

Elective Information

Host Site Information:

Academic Information:

Health Information:

Please note: