Lambarene Application Form Applications are now being accepted. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* School*Will you have completed clerkships in medicine, pediatrics, and surgery at the start of the Fellowship rotation (February 1 – April 30 or May 1 – July 31)?*YesNoClerkship Comments:If selected to serve as a Fellow what time period would you be available to serve?:*February 1-April 30 ONLYMay 1-July 31 ONLYFebruary-April OR May-July 2017Are you fluent in French*YesNoWhat are your experiences speaking French?:*What is your motivation for applying to the Lambaréné Schweitzer Fellowship?:*What do you hope to contribute to the Hospital and community?:*Please discuss previous relevant experiences, including those interacting with other cultures, working or traveling internationally, and serving as a volunteer:*Reflect on the ways in which you anticipate a fellowship in Lambaréné might broaden your experience and shape your future professional and personal goals:*What does it mean for you to belong to a network of 'Fellows for Life'?:*11. Please list the contact information for three references. At least one reference should be a faculty member from your school who could serve as your Academic Mentor for the Schweitzer Fellowship. For each reference, describe your relationship in one sentence and include contact information such as telephone number and email address.Reference 1/Proposed Faculty Mentor:*Reference 2*Reference 3*Please upload your resume as a PDF document*Accepted file types: pdf. This iframe contains the logic required to handle AJAX powered Gravity Forms.