Global Health Office

Faculty of Medicine

Service Learning Application Form

Service learning requires a minimum commitment of 20 hours and will appear on your transcript as MEDI 2612.

Registration for this program is only available to Med 2 students at this time.

The Service Learning Leadership Committee will review applications and match students to community organizations.

Complete the attached application form and submit to Sarah Peddle.

Applicant Contact Information

Name

Year of Study

Campus (Halifax or Saint John)

Phone Number

E-Mail Address

Availability

During which hours are you available to participate in on-site service learning experiences?

Weekday mornings

Weekday afternoons

Weekday evenings

Weekend mornings

Weekend afternoons

Weekend evenings

Please provide details (hours and days) of availability

Top three Service Learning Experience Choices

Please tell us, in order of preference (1 being the most preferred), which service learning experiences you are most interested in.

Please indicate the organization name and the project number (if applicable)

Special Skills or Qualifications

Summarize special skills and qualifications you have acquired from education, employment, previous volunteer work, or through other activities, including hobbies or sports. If your ideal service learning experience requires particular qualifications, this is where you provide details to help the committee determine appropriate matches.

Person to Notify in Case of Emergency

Name

Street Address

City, Postal Code

Phone Number

E-Mail Address

Agreement and Signature

I understand that participating in this program means that I am representing the medical school in the community and will conduct myself in a professional and courteous manner.

Name

Date

Captcha

Dalhousie University

Global Health Office

Service Learning Application Form

Applicant Contact Information

Availability

Top three Service Learning Experience Choices

Special Skills or Qualifications

Person to Notify in Case of Emergency

Agreement and Signature