Application Form: Post Graduate Course in Paediatric
Gastroenterology, Hepatology and Nutrition
Hosted by: University of Cape Town- School of Child and Adolescent Health
and Stellenbosch University
Supported by ESPGHAN
Educational Grant provided by the Nestle Nutrition Institute
Cost : The course includes all material, accommodation and travel costs. An administrative
fee of R1000 is applicable on acceptance of the application.
Dead line for Submission: 15/1/2013
Submit applications to: Ms J De Wet, Red Cross War Memorial Children’s Hospital, Klipfontein Road,
Rondebosch, 7700, Room 519, 5th floor, ICH Building, South Africa OR Judith.dewet@uct.ac.za/
liz.goddard@uct.ac.za, +27 21 658 5316
Personal Information
Surname
First Name(s)
Date of Birth
(dd/mm/yyyy)
Citizenship
Present country of
residence
ID number
Passport number
Present residential
address
Telephone
Present address of
employment
Telephone
Email address
Education and Experience
Medical Qualifications (list name, year obtained, institution)
Record of previous positions held (list years of employment, institution, and
positions held) and present position held
Motivation : Write a short motivation on the reason this course will benefit you
Please attach a Summary CV (1 page)
Signature (Applicant)
Date
Signature
Date
Head of Department (Confirm that the applicant will be permitted to attend the course)