JOHNS HOPKINS UNIVERSITY BLOOMBERG SCHOOL OF PUBLIC HEALTH
SUMMER INSTITUTE IN TROPICAL MEDICINE AND PUBLIC HEALTH
INTERNATIONAL STUDENT APPLICATION FORM – SUMMER 2010
INSTRUCTIONS: This form is ONLY for international applicants WHO WILL REQUIRE A VISA to enter the US, and is not to be used by applicants who are US citizens or permanent residents, or by foreign students who already possess a valid visa. Finally, this form is to be submitted PRIOR TO MARCH 8 TH , 2010; after March 8th, all applicants should use the online application system (ISIS) available on the Summer Institute website
(http://www.jhsph.edu/tropic/application.html). When complete, please email this form to: sslimited@jhsph.edu
PERSONAL INFORMATION (Please print)
Title : Mr. Ms Dr.
Name :
First
Occupation :
Title :
Office Address:
Middle Initial Last Gender (M or F)
Street
Phone :
area code/number
Home Address:
Street
Fax: city city
area code/number state/country state/country
zip zip
Country of Legal Residence: Phone:
Country of Citizenship (only if applying for a B1/B2 visa to attend):
Email:
Indicate your preferred mailing address: Home Office
Required only if enrolling for academic credit courses:
Social Security Number (leave blank if none):
PROFESSIONAL EXPERIENCE
(Three most recent starting with current)
Employer Position/Title
1.
2.
3.
EDUCATIONAL BACKGROUND
(Start with most recent university/college degree)
Area of Concentration School
1.
2.
3.
Activities
Date of Birth:
Degree
Dates
Year Received

YOUR JHU AFFILIATION (Please check all that apply)
 Alumnus  Employee  Attended Continuing Education Course
Are you currently enrolled in a degree program at The Johns Hopkins University? Yes No
If so, which school, department and degree?
Are you currently an MPH candidate at JHSPH? Yes No
Are you currently an DrPH candidate at JHSPH? Yes No
How did your hear about the Tropical Medicine Institute?
Brochure Colleague Internet Other:
If you have any special needs, please let us know.
I certify that the information given by me on this application is complete and accurate in every respect, and I understand that any misrepresentation or omission may be cause for denial of registration or revocation of academic credit. While attending the Summer Institute in Tropical Medicine and Public Health, I will adhere to all rules and regulations applicable to students at the Johns Hopkins Bloomberg School of Public Health, including but not limited to the Student Conduct
Code and the Student Honor Code.
Signature of Applicant: Date:
PLEASE CHECK COURSE SELECTIONS:
HIV, Tuberculosis and Chronic Infections in the Tropics
Vector-Borne Diseases in the Tropics
Intestinal Infections in the Tropics
Child and Public Health in the Tropics
(June 21 – July 2)
(July 5 – July 16)
(July 19 – July 30)
(August 2 – August 13)
TUITION DUE:
Academic Credit: $862 (subject to change) per credit unit (maximum of $10,344 for all four modules)
Non-Credit: $1,450 Per Course (maximum of $5,800 for all four modules)
Course fees: $30 per course (maximum of $120 for all four courses), not included in tuition
CREDIT DESIRED:
Academic credit Non-Credit (Certificate of participation)
PAYMENT METHOD:
Tuition Remission Voucher Check (payable to JHU Tropical Medicine Institute) #
Purchase order or contract documents Credit Card: Visa MasterCard Discover
Exp. Date Card #
Billing Address:
Name as Printed on Card:
Signature:
Application Non-refundable Deposit ($200) (to be applied to tuition)
Total Enclosed
Balance Due in advance or at final registration
$
$
$

Johns Hopkins Bloomberg School of Public Health
Summer Institute Office
615 N. Wolfe St. Rm W1101
Baltimore, MD 21205 sslimited@jhsph.edu
(443) 287-8740
Any questions regarding the modules in the Tropical Medicine Institute please, contact the Program Coordinator at tropmed@jhsph.edu
, or by telephone at (410) 614-3639.