APPLICATION FOR ADMISSION INTO A MEDICAL PROGRAM

APPLICANT INFORMATION AND PREFERENCES:

Applicant's full name *

Gender *

Country of birth *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Mother's name *

Father's name *

Full address *


Street Address Line 2

	Country

Telephone number *

E-mail *

Date of birth *

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Citizenship *

Passport number *

Passport issuance date *

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Passport expiry date *

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Current occupation *

ADADAMIC BACKGROUND:

Institution which certified your studies *

Date of graduation (pre-university/ high school or equivalent) *

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REQUESTED ACADEMIC PROGRAM DETAILS

Program Requested *

Is Spanish your mother tongue? *

CONTACT PERSON IN CASE OF EMERGENCY

Full Name

Relationship *

E-mail

Phone Number

Full address *


Street Address Line 2

	Country

ACCOMMODATION PREFERENCE

Note: Accommodation in a university residency is compulsory for the first year of an undergraduate program in any medical specialty. Those starting an undergraduate program must choose one of the following two options:
1- University Residency in Cojímar (for students starting premed and Spanish courses students); or
2- Residency (for students starting medical careers)

Accommodation preference *

Do you prefer to live alone? *

HAVE YOU/ DO YOU HAVE ANY OF THE FOLLOWING MEDICAL CONDITIONS

Lung disorder *

High blood pressure *

Heart condition *

Disease of the kidney *

Malaria *

Any form of cancer *

Disease or disorder of the digestive tract *

Diabetes *

Chronic hepatitis with positive antigen *

Marked Cifo- scoliosis *

Dwarfism *

Rhinolalia *

Acromegaly *

Pemphigus *

Leprosy *

Chorea or Athetosis *

Ankylosis of large joints *

Retinitis Pigmentosa *

Blepharospasmor Bilateral Ptosis *

Generalized Dermatitis *

Ataxia *

Sever Epilepsy *

Paralysis of limbs *

Congenital Glaucoma *

Bilateral Congenital Cataract *

Bilateral severe hearing loss or kyphosis *

Mental deficiency of any degree *

Cyanotic Congenital Heart disease *

Voice and/ or speech disorders *

High degree of stuttering *

Any kind of active Tuberculosis *

Discoid Fixed Lupus Erythematosus *

Amputation of the fingers in one or both hands affecting manual skills *

Personality disorders in a permanent state of inadequacy or frequent periods of decompensation *

Total amputation of limbs or segments of members, excluding lower limbs that are partial and do not require the use of prosthesis *

Curvature, shortening or lengthening of members that limit their functions or wearing of special uniforms or footwear *

Aftermath of traumatic injuries, burns or surgery, or keloid scars shrink, which makes movement difficult or produce functional disability or serious aesthetic problems or interfere with wearing special uniforms or shoes *

Genodermatosis, Ichthyosis (according to location and extent of the injury). Epidermolysis Bullosa, Xeroderma Pigmentosum, Von Recklinghausen disease *

Psychiatric disorders in the form of permanent or frequent seizures despite treatment *

Congenital Malformations or permanent disfigurements due to any cause *

Sickle Cell Anemia(Sicklemia), Hypoplastic or Aplastic Anemia *

Congenital or acquired Heart disease with physical limitations *

*

Date of last tetanus shot: *

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UPLOAD:

If you are interested in Visits, Residency, Fellowship or Internships program(s), please disregard the upload section below

Copies of pre-university studies 1

Copies of pre-university studies 2

Copies of Immunization report

POLITICAL AFFILIATION

*

HOBBIES and INTERESTS

IMPORTANT NOTICES:

1- This is an official form which will be submitted to the Cuban Academic Services Authorities (CASA); please fill out all mandatory fields.

2- For enrollment to be officiated in any of the medical programs, the following must be in the student’s possession upon arriving in the Republic of Cuba:

- Certified copies of pre-university studies, High School or its equivalent level according to the country of origin. Said copies must be certified and legalized at the Cuban embassy in the student's country of residence.

- Ten (10) 1x1 inch size photos.

- Legal Documents from the country of origin certifying that the applicant has no criminal record, legalized by the Embassy of the Republic of Cuba in the country of origin or residence

- Health Certificate issued three months prior to the beginning of the educational program. Said certificate must be legalized by the Embassy of the Republic of Cuba in the country of residence. The certificate must state the applicant does not have any illness that could invalidate him/ her from enrolling in any medical education program in the Republic of Cuba. Failing to do so will result in the immediate return of the student to the country of origin and reimbursements of the cost of the program. Furthermore, and upon the student’s arrival to the Republic of Cuba, and should a student be diagnosed with any disease that could result in invalidating his/ her study, said situation will result in the immediate return of the student to the country of residence and reimbursements of the cost of the program.

Copies of the above records must be submitted to and certified by the Cuban embassy in your home country upon receiving the addmission acceptance letter from The Cuban Academic Services Authorities (CASA). Additional guidance and assistance would be extended to you via our teams upon receiving the said letter.

Should you agree to the above, please affix your signature below

Signature *

Clear

IMPORTANT NOTICE REGARDING THE INITIAL DEPOSIT:

Starting August 1, 2015, please be advised that CubaHeal will request a $135.00 CAD initial deposit for the submission of STUDENT APPLICATION FOR ADMISSION INTO A MEDICAL PROGRAM to the Cuban Academic Services Authorities (CASA) for assessment which will be deducted from the total cost of the program(s). This is due to the fact that it has come to our attention that a number of applicants who have been granted enrollment approval in Cuba were only interested in receiving free consultation. In our opinion, this is an unfair conduct since:

1. The Cuban Academic Services Authorities (CASA) have taken the time to review and assess the applicant’s file; and

2. Possible assignment of enrollment or visits spots for an applicant which could result in creating a longer waiting period for other students and visitors.

Furthermore, please take note of the following:

1- Should the Cuban Academic Services Authorities (CASA) approve an applicant's application, Cubaheal Medical Tourism Inc. will subtract the initial deposit from the total cost of the program;

2- Should the Cuban Medical Authorities refuse an enrollment or visit application, CubaHeal Medical Tourism Inc. will refund the full amount; and
3- If an applicant is approved by the Cuban Academic Services Authorities (CASA) but decides not to accept the offered program, CubaHeal Medical Tourism Inc. will consider said initial deposit as a consultation fee and will not refund it.

Sincerely yours,

CubaHeal sales team

Please note:

For those who do not possess a PayPal account, you could always make the initial deposit using your credit card. For further information, please contact CubaHeal Admin at admin@cubaheal.com in order for them to forward a document containing credit card payment instructions.

INITIAL DEPOSIT *

Initial Deposit $ 135.00 CAD

Total $ 0.00 CAD