ELIGIBILITY: Anyone who is a health care professional in any discipline is encouraged to apply to this program.
APPLICATION INSTRUCTIONS
1. Please fill out the two page application below completely.
2. Please write a 1-page, double-spaced essay in English. In the essay, please discuss the reason(s) you would like
to participate in the International Leadership in Health Program, and how this program may benefit you in your
professional role. One of the components of this program will be matching each participant with a University of
Alabama in Birmingham (UAB) faculty “coach”, to assist participants with creating their personal leadership
development plans. Some participants and coaches may be interested in continuing their relationship beyond
the 2 week program at UAB. Please indicate in your essay whether you would be interested in continuing to
work with your coach on projects after the 2 week program (such as developing collaborative projects,
manuscripts, or maintaining ongoing communication as you implement your leadership development plan).
3. Please request and submit a letter of support from your supervisor. This letter should come from your
supervisor and indicate support for your participation in the 2 week leadership program.
4. Please submit an updated resume or curriculum vita (CV)
5. Please email or fax the above four documents to Lisa Theus, Program Coordinator. (contact info below)
Your application, essay, support letter and curriculum vita/resume, are due no later than March 1, 2014. Applications
received by February 1, 2014 will be given preference. Applicants will be notified of acceptance status by March 15,
2014. If you are accepted into the program, you will need to send us a copy of your airplane ticket by May 1, 2014 to
hold your space in the program. The total fees for the program will be due on the first day of the program in U.S. dollars
by certified check, cash or money order (fees due July 7, 2014 if you attend English classes or July 14 if you do not attend
English classes). The total tuition, lodging and other fees due will be between $1,500 and $2,300 depending on whether
or not you take the ESL course and what lodging you choose. (see additional info sheet for cost breakdown).
There are a limited number of host families who will provide lodging and some meals at no charge. Please indicate if
you would like to stay in campus housing or if you would like to stay with a host family. We will let you know as soon as
possible whether or not we can accommodate your choice.
 campus housing
 host family
Our leadership program is one of the best in the U.S. and is offered at the lowest cost to participants in an on-site
course. In addition to the low cost of tuition and lodging, there are some associated fees including health insurance,
medical clearance, SEVIS, visa, food and miscellaneous expenses (see cost breakdown below) Thank you for your interest
in this exciting program! If you have any questions, please contact Dr. Lynda Wilson, Program Director.
Lynda Wilson, RN, PhD, FAAN
Professor, Assistant Dean for International Affairs and
Deputy Director, PAHO/WHO Collaborating Center on International Nursing
Phone: 205.934.6787 Fax: 205.996.7813
Email: lyndawilson@uab.edu
Lisa Theus, MSPH
Program Coordinator for International Affairs
Phone: 205.996-7621 Fax: 205.975.6194
Email: theusL@uab.edu
PAHO/WHO Collaborating Center on International Nursing
International Leadership in Health Program Application
July 14-25, 2014
(Optional English classes July 7-11, 2014)
Co-Sponsors: UAB Sparkman Center for Global Health and the UAB English Language and Culture
Institute
General Information
Name: ____________________________________________________________________________________
Family Name(s)
First Name
Middle Name
Date of Birth :_________________________
(month, day, year)
Gender:
Place of Birth: ___________________________________
(city, country)
□ Male □ Female
Current Mailing Address:
__________________________________________________________________________________________
Street Address
__________________________________________________________________________________________
City
State/Province
Postal Code
Country
Daytime Telephone Number:__________________________________
Evening Phone Number :_____________________________________
Fax Number:_______________________________________________
Email Address:_____________________________________________
Country of Citizenship: ___________________________________________________
Country of Residence:_____________________________________________________
Where do you work?_________________________________________________________________________
What is your job title? _______________________________________________________________________
If Student, Name and Year at University : Name of University ______________________________________
Year at University:
□1st
□ 2nd
□ 3rd
□ 4th
Language Study Information
Do you plan to enroll in the optional English Classes to be held July 7-11, 2014? ___ Yes ___ No
(If yes, please note that there is an additional fee for this class). If “yes”, please complete the following
information. If “no,” please skip to the section called “Application Information.”
How many years have you studied English?_______years ; Do you have a TOEFL score? □ Yes □ No
If yes, what is your TOEFL score? _______
Dates of English language study: from (month/year) _______to (month/year)________
A basic level of English proficiency is required to participate in this program, since all classes will be taught in
English. By basic, we mean that you are able to speak, read, and write in English at a basic level of
comprehension. In order to assess your level of English, we ask you the following three questions:
1.
If you have taken the TOEFL examination, please provide your score and date of the exam.
2.
Please list English language training courses you have had and where (including places in home
country). Attach additional page if necessary. Include content of course (general English, writing, etc.)
Course
3.
Content
Location
Please rate your current level of English:
Beginner Levels
□
□
□
1
2
3
Intermediate Levels
□
□
□
4
5
6
□
7
Advanced Levels
□
□
□
8
9
10
Are you proficient in any other language? If so, which ones?
________________________________________________________________________
ADDITIONAL INFORMATION
ESTIMATED COST OF 2-WEEK PROGRAM:
Two-week Leadership Program
Tuition:
$700
Lodging:
$260* (double occupancy)
Health Insurance:
$95 (or more, if you’re over 60)
Medical Clearance Fee:
$125
SEVIS:
$180
Visa:
$150
Total:
$1,500 each participant
*$520 for single room
Remember there are other expenses such as food, personal miscellaneous costs, ground transportation y
AIRFARE which are not listed above. If you come one week early to take the English course, please add $550 for the
course, $34.50 for insurance, and $140 (double) or $280 (single) for lodging.
Application Checklist – please check each item to be sure your
application is complete!
Completed application form
One-page essay in English
Letter of support from supervisor
Copy of resume or curriculum vita
Please email or fax completed application with other listed items to:
Lisa Theus, MSPH
Program Coordinator for International Affairs
Phone: 205.996-7621 Fax: 205.975.6194
Email: theusL@uab.edu