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Application Form
LearnToLive Application Form
We'd like to get to know you a little bit, ask you a few questions, and you can tell us a few stories! We'll get the boring stuff out of the way first, then you can select which program you'd like to apply to. nn*Fret not! All your information is stored securely and never shared with any party/company/person outside of LearnToLive.*
Step 1 of 7
14%
Full Name
*
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Last
Phone Number
*
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*
Address Details
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Street Address
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Afghanistan
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Afghanistan
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Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
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Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
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Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
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Tuvalu
Uganda
Ukraine
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Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Sex
*
Female
Male
N/A
Birthday!
*
Date Format: MM slash DD slash YYYY
Personal Questionnaire
Now you can tell us a little more about you!
What is your profession?
*
Lots of people have one job, but experience in many others. Tell us what fields you've worked in:
Health
Administration
Engineering
Construction
Design
Science!
Law
Business
Why do you want to be a part of LearnToLive?
*
What awesome skills can you bring to the table?
*
If you could go anywhere in the world, where would you go?
*
What are your super powers, otherwise known as strengths? What are your weaknesses?
*
Please describe your communication style, especially with regards to working within a large group
*
Do you enjoy new and exciting foods?
*
Yes! Bring it on, I'll try almost anything!
Maybe once I see you eat it, I'll give it a try...
Third ChoiceI stick to what I know.
How would you handle the following situations?
You've just arrived in Indonesia for your 3 week stay as a volunteer with LTL, but your baggage never left your last transit point!
*
While working at the LTL accommodation, the power has been going out on a daily basis for long periods of time. Access to wifi is sporadic and slow at night, or non existent during the day.
*
You have a four hour car ride ahead of you, up rocky and uncomfortable roads, to a remote mountain village that the project services.
*
Which program are you interested in applying to?
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Indonesian Health Initiative
Water Design/Build Project
Global Health Student Program
Laos Maternal & Child Health Program
LTL Scan Program
The Tomohon Community Mental Health Project
Are you flexible with your role within our crew? One day we may need you to work in the clinic as a pharmacist, then next day we may need you to help with the nutrition education with the kids and the next day you may need to drag wood up a hill, would this be something you can handle?
*
Are you willing to share Hotel Accommodations?
*
Yes
No
Are you a health care professional?
*
Yes
No
Tell us about your role in healthcare & how long have you been practicing.
Clean Water Design & Build Projects
The Water Project Design & Build runs alongside our Indonesian Health Initiative in North Sulawesi Indonesia.
We’re interested in what particular set of skills can you bring to the water project! Tell us about the kinds of projects have you created / built / planned / or collaborated on in the past?
*
Tell us how you would handle the following situations:
Due to the remote locations of some of the water projects, you may be living in a village with your team members for a week away from the medical team, wifi, or even a store that serves cold drinks.
*
You’ve been working in the sun for several hours and feel a bit lightheaded. What do you do?
*
The Tomohon Community Mental Health Project
The Tomohon Project will be running year round in Tomohon, North Sulawesi Indonesia starting in July 2016 with residents on a revolving time table.
Name of Residency Training Program
Program Director Name
Current Level of Residency Training
2nd Year
3rd Year
4th Year
Graduate
Do you have any prior international travel experiences?
*
Yes
No
Where have you traveled?
Do you have any international medical experiences?
*
Yes
No
Please describe your international medical experiences
Please describe a specific area of community psychiatry that you are most interested in
*
Why do you want to be a part of LearnToLive's Tomohon Project?
*
As part of the LTL program, we are working on anti-stigma and community awareness programs. Please describe some ideas that you have that you might implement during your time before, during, or after you time with the program.
*
Do you have any research experiences?
*
Yes
No
Would you like to participate on the ongoing LearnToLive IRB projects?
Yes
No
Do you have a prefered time for participating? We will be initiating this project July 2016. Please give us an estimated start date.
Date Format: MM slash DD slash YYYY
How long are you available to participate? Ideally we would like people to commit to a minimum of 2 weeks and preferably 3 weeks or more
*
2 weeks
3 weeks
4 weeks or more
Global Health Student Program
The Global Student Health Program runs alongside our Indonesian Health Initiative in North Sulawesi Indonesia. This is a wonderful opportunity for health science students to work alongside international medical professionals, gain community health experience, and learn about global health priorities in challenging environments.
Academic Institution
*
Field of study/concentration/ major
*
At what stage will you be in your degree at the start of the program?
*
1st Year
2nd Year
3rd or Final Year
Please describe the placement or field relate work opportunities you have experienced to date.
*
Why do you want to work on a placement in Indonesia?
*
What skills/attributes can you bring to the program?
*
How will you prepare for your placement with LTL Indonesia?
*
Laos Maternal & Child Health Program
The Laos Maternal & Child Health Program runs for 10 days during January in Mok Mai, Laos - 8 hours outside of Vientiane. This program helps improve the health of mothers & babies, educate young women & men, and trains new ultrasound technicians.
Real quick, just so we can note it, can you let us know if you are any of the following:
*
Nurse
Midwife
Maternal Child Health Specialist
Doctor
Health Educator
Tell us about your roles in the health and how long you’ve been practicing.
*
Tell us about some of your experiences in health education or patient education
*
Do you have any experience with ultrasound machines?
*
Yes
No
Please describe your experience with ultrasound machines
*
LTL Scan
The LTL Scan program runs concurrently with existing LTL programs. This program is run by two ultrasound specialist and provides a week long curriculum on sonography related to pregnancy and trauma (FAST).
Are you a healthcare professional? Tell us about your roles in the health and how long you’ve been practicing.
*
Do you have any experience with ultrasound machines?
*
Yes
No
Please describe your experience with ultrasound machines
What is your experience teaching medical education
*