Educational Ambassadors Program
Application to become an ISN Educational Ambassador
ISN-GO encourages centers in the emerging world to submit requests to the Educational Ambassadors Program for handson training related to specific educational needs. Training requests are matched to qualified, available and approved
experts. In order to identify successful matches, the ISN depends on the largest possible pool of potential volunteer
experts who are willing to spend 1-4 weeks away from home. The ISN invites you to sign up as a potential Educational
Ambassadors
Applicants must meet the following requirements:

Active ISN membership

Expertise in a defined area of renal medicine documented by publications in peer-reviewed journals.

An active faculty appointment at an accredited institution (Medical School, Clinic, Hospital).

Willing, if invited, to free some time (at a time negotiated with the requesting center) for at least 1 and up to 4
weeks teaching in a developing nephrology center.

Confirm your adherence to ISN principles and procedures including the Declaration of Istanbul
ISN Global Operations Center
Ms. Giorgia Manuzi
Global Outreach Programs Administrator
Rue des Fabriques 1B, 1000 Brussels - Belgium
Phone: +32 2 808 04 20
Fax: +32 2 808 44 54
E-mail: gmanuzi@theisn.org
Website: www.theisn.org
There is no specific deadline for submission of applications. Applications can be submitted throughout the year. A board of
reviewers will assess your application before you are formally recognized as a potential ISN Educational Ambassador.
Outcomes of applications will be communicated within a month.
Please send this form together with your CV by post, fax or e-mail as is most suitable to you. Scanned copies are sufficient
and acceptable.
For any questions, do not hesitate to contact Giorgia Manuzi at the ISN Headquarters.
CONTACT DETAILS
1. YOUR CONTACT DETAILS
Last Name:
First Name:
Date of Birth:
Gender:
Male
Female
E-mail:
ISN Member:
Yes
No
ISN Membership ID:
2. INSTITUTION DETAILS
Name:
Address:
Country:
City:
Postal Code:
Phone:
Fax:
1
Director:
E-mail:
Your Current Position:
ELIGIBILITY AND QUALIFICATIONS
1. Please select your defined area(s) of expertise in renal medicine most relevant to this program:
Dialysis
Transplantation
Epidemiology
Clinical Nephrology
Acute Kidney Injury
Interventional Nephrology
Renal Pathology
Critical Care Nephrology
Education Teaching - Please specify area:
Other - Please specify area:
2.
Are you willing/able to initiate and develop community based prevention screening programs
Yes
No
3.
Please list your publications in peer-reviewed journals which document your expertise in the above area(s)
4.
Please briefly list your current and past appointments at accredited institutions
5.
Please summarize any previous teaching experience/activities in emerging countries
6.
Please briefly state your motivation for participating in this program
PREFERENCES
1. AVAILABILITY FOR TRAINING
Potential availability for onsite training:
1 week
2 weeks
3 weeks
4 weeks
Flexible as per request/ negotiable
Comments:
Time(s) of the year that you can NOT be available:
2.
LOCATION OF TRAINING (Specific locations or centers can be identified)
Preferred regions of placement:
Africa
Middle East
Eastern & Central Europe
Russia & CIS
Oceania & South East Asia
South Asia
East Asia
Latin America
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Countries/areas you prefer not to travel to for political/religious/ideological reasons:
*your preferences will remain confidential.
2
COMMENTS/FEEDBACK
SIGNATURE & PERSONAL GUARANTEE FOR THE ISN
I adhere to the Declaration of Istanbul
By endorsing the Declaration of Istanbul, I commit to uphold the principles of Declaration in my practice and teaching and
will strive towards achievement of the proposals of the Declaration.
Signature
Date
Upon signing and submitting this form you, as a volunteer, acknowledge and accept the following:

Some details related to your professional background will be included in a database of approved volunteers,
which is published on the ISN Gateway. Please note that your personal contact details will not be available on
the website.

The ISN staff can contact you to check your availability and initiate arrangements for a possible training visit and
will require a timely response from you

ISN is unable to guarantee that your name will be matched to a successful request for training. This is why we
encourage you to activate any contacts in emerging countries you may already have to apply for support from
this program.

3 consecutive refusals to accept invitations to participate may result in your name being removed from the
database and program

You commit yourself to deliver the best possible and well prepared educational opportunity to those who have
requested an expert to come and deliver training

You agree to submit a report within the 30 days following your visit to a the host center

Although ISN will not knowingly support visits to endangered areas, ISN cannot be held liable for any
consequences related to traveling or staying abroad. The responsibility for procuring health/accident and travel
insurances remain with you; you or your relatives cannot hold ISN responsible in the event of untoward events
or experiences
Signature
Date
3