CHINA CALIFORNIA HEART WATCH
www.chinacal.org
2012 Application to Participate in Medical and Public Health Student Clerkship in Yunnan Province, China
Complete this form and waiver and send to Roy Chan at rychan@uci.edu and to Robert Detrano at Robert@chinacal.org. We will contact you soon thereafter.
This is not a vacation or a tour. This is an opportunity to obtain first hand experience of medical problems and care in the impoverished communities of rural Yunnan Province and the city of Kunming. This is a service to the poor rural people of Yunnan province. Interns will participate and help in clinical care and research in impoverished areas of Yunnan Province. See description of internships at http://www.chinacal.org/clerkship.html.
To participate, you must qualify. Please answer the following questions using this Word document, then print, sign and scan the Release and Waiver of Liability form at the bottom. Return the completed application form and the scanned, signed copy of the Release and Waiver of Liability form to: robert@chinacal.org
Demographic and Contact Information:
| Name (as in passport): | |
| Email: | |
| Phone Number: | |
| Address: | |
| Age: | |
| Passport Country: | |
| Passport Number (Chinese id Number): |
Emergency Contact Information:
| Name of Emergency Contact: | |
| Relationship: | |
| Phone Number of Emergency Contact: |
Medical Information:
| List allergies: | |
| List and describe any serious illnesses or disabilities: |
Application Questions:
| What is your academic level (undergraduate, graduate student, other)? | |
| What is your specialty or major (e.g., medicine, public health, social work, psychology, etc.)? | |
| Do you speak Mandarin? (Y/N) | |
| If yes, is your Mandarin:a) Elementary (can ask directions but cannot converse or read)b) Intermediate (can carry on casual conversation and can read a little)c) Advanced (can teach and read well)d) Fluent | |
| In the space to the right, please describe your career goals and how this experience will help you in your avowed career. (≤200 words) | |
| When will you be available for a phone interview? (provide date) | |
| Which internships are you available to attend? (list all that apply)a) Juneb) Julyc) Augustd) September
e) December |
Thank you for your interest in China California Heart Watch. We will be in touch shortly regarding your application. In the meantime, please continue to familiarize yourself with our organization by visiting www.chinacal.org. There is a requested donation associated with this internship. See description of internship on our website.
CHINA CALIFORNIA HEART WATCH
Release and Waiver of Liability for China California Heart Watch
In consideration for being permitted to participate as an intern of China California Heart Watch (“CCHW”), the undersigned, for himself or herself, his/her personal representatives, heirs and assignees, and next of kin, acknowledges and agrees to the following terms and conditions of participation:
1. The undersigned HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE CCHW or any of, its officers, directors, employees or agents for any claim, cause of action, loss, damage or tort arising out of or relating to his or her participation as a CCHW intern or any related activities. This RELEASE and WAIVER applies to any claim or demand on account of injury to the person or property resulting to the undersigned whether caused by negligence or otherwise while the individual is involved or participating in any activity relating to CCHW.
2. The undersigned HEREBY ASSUMES FULL RESPONSIBILITY FOR AND ALL RISK OF BODILY INJURY, DEATH OR PROPERTY LOSS due to negligence or otherwise while said individual is participating in activities relating to CCHW. The undersigned EXPRESSLY ACKNOWLEDGES AND AGREES that some of the activities in which the undersigned will engage during the internship might involve substantial risk of serious injury and/or death and/or property damage. The undersigned nevertheless expressly agrees that the foregoing RELEASE AND WAIVER is intended to cover all such activities and that the foregoing RELEASE AND WAIVER is intended to be as broad and inclusive as permitted under the laws of the State of California and of the People’s Republic of China.
3. The undersigned EXPRESSLY ACKNOWLEDGES AND AGREES that CCHW may use images of the undersigned, whether on film, video, electronic media or other format, for publicity, fundraising and recruiting and any other purpose which CCHW may deem appropriate, and the undersigned further acknowledges that there will be no compensation from CCHW to the undersigned at any time for such use of such image(s).
4. If any portion of this RELEASE AND WAIVER is deemed invalid, it is agreed that the balance of the RELEASE AND WAIVER shall remain in full force and effect. The undersigned also expressly agrees that (s)he has READ AND VOLUNTARILY SIGNED THE RELEASE AND WAIVER OF LIABILITY and understands that (s)he is giving up substantial rights, including the right to sue, and intends for his/her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
Name of Intern _____________________________________________ Age ______________
Signature of Intern _________________________________ Date: ________________________
CHINA CALIFORNIA HEART WATCH
www.chinacal.org
Release and Waiver of Liability for China California Heart Watch
In consideration for being permitted to participate as an intern of China California Heart Watch (CCHW), the undersigned, for himself or herself, his/her personal representatives, heirs and assignees, and next of kin, acknowledges and agrees to the following terms and conditions of participation:
1. The undersigned HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE CCHW or any of its officers, directors, employees or agents for any claim, cause of action, loss, damage or tort arising out of or relating to his or her participation as a CCHW intern or any related activities. This RELEASE and WAIVER applies to any claim or demand on account of injury to the person or property resulting to the undersigned whether caused by negligence or otherwise while the individual is involved or participating in any activity relating to CCHW.
2. The undersigned HEREBY ASSUMES FULL RESPONSIBILITY FOR AND ALL RISK OF BODILY INJURY, DEATH OR PROPERTY LOSS due to negligence or otherwise while said individual is participating in activities relating to CCHW. The undersigned EXPRESSLY ACKNOWLEDGES AND AGREES that some of the activities in which the undersigned will engage during the internship might involve substantial risk of serious injury and/or death and/or property damage. The undersigned nevertheless expressly agrees that the foregoing RELEASE AND WAIVER is intended to cover all such activities and that the foregoing RELEASE AND WAIVER is intended to be as broad and inclusive as permitted under the laws of the State of California and of the People’s Republic of China.
3. The undersigned EXPRESSLY ACKNOWLEDGES AND AGREES that CCHW may use images of the undersigned, whether on film, video, electronic media or other format, for publicity, fundraising and recruiting and any other purpose which CCHW may deem appropriate, and the undersigned further acknowledges that there will be no compensation from CCHW to the undersigned at any time for such use of such image(s).
4. If any portion of this RELEASE AND WAIVER is deemed invalid, it is agreed that the balance of the RELEASE AND WAIVER shall remain in full force and effect. The undersigned also expressly agrees that (s)he has READ AND VOLUNTARILY SIGNED THE RELEASE AND WAIVER OF LIABILITY and understands that (s)he is giving up substantial rights, including the right to sue, and intends for his/her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law.
| Name of Intern: | Age: |
| Signature of Intern: | Date: |
{LF019013.DOC.1}