Global Health True Leaders 2016

Application Form
DEADLINE: MAY 8, 2016
SECTION 1: REGISTRATION FORM
Participant information:
Gladys
Olivia Vivian
Siregar
First Name:_____________________
Middle: _____________________
Last:____________________
Gladys
Nick Name:___________________________________________

Please thick one:

Undergraduate Student

Health Practitioner

Graduate Student

Please fill it if you are an undergraduate student

Semester (thick one):

4th

5th

6th

7th

8th

Andalas
University
Andalas University
Current University:________________________________________________________
Faculty
of Medicine
Faculty of Medicine
Faculty: _________________________________________________________________

Jalan
Perintis
Kemerdekaan,
Jalan Perintis
Kemerdekaan,
Padang Padang
University address: ________________________________________________________
2020
3,36
3,36
2020
Expected graduation date: ___________________
Current GPA: ___________________
Please fill it if you are a health practitioner or graduate student

Current Company/Faculty-University:_________________________________________________
Company/Faculty-University address: _________________________________________________
Study Background: ________________________________________________________________
Graduated date: _________________________________ Previous/Current GPA: _____________

08
September
1995
Birth Date: Date_________
Month_________________________
Year______________
Jalan Koto Tinggi 4A
Current Address: ______________________________________________________________________
Padang
Sumatera Barat
City:______________________________
Province:_________________________________________
21520 ___________________
Indonesia
Country:__________________________________
Zip code:______

Phone Number: Home________________________

081372395673
Mobile______________________________

gladysglados@gmail.com
Email Address:_____________________________________________________________________
Indonesian
Citizenship: ___________________________________________

Global Health True Leaders 2016

Application Form
DEADLINE: MAY 8, 2016
Parent/ Guardian Information
Laura Ance Sinaga
Parent Name:______________________________________________________
____________________
Parent Phone Number: Home__________________________

081361246126
Mobile__________________________

dhs_agara@yahoo.co.id
Parent Email Address: _____________________________________________________________________
Jalan Menteng VII Gang Bahagia II No. 7 Medan
Parent Street Address (if different from above):_______________________________________________
Firdaus
Emergency Contact: Name__________________________
Phone Number___________________________

SECTION 2: HEALTH INFORMATION

Physical Limitations:_____________________________________________________________________
Dietary restrictions:_____________________________________________________________________
Please list any known allergies:____________________________________________________________
Please mention your illness record:_________________________________________________________

_____________________________________________________________________________________
Please list any other health concerns you may have:___________________________________________

SECTION 3: EDUCATION
List the college you have attended starting with the most recent:
College

Major

Graduated Year

Expecting Graduate Year

Your Previous or Current College

Your Previous or Current Major

Year that You Graduated

Year that You Expecting to Graduate

Andalas University

Faculty of Medicine

2020

SECTION 4: Current Business and Employment History (if applicable)

Company:

From (MM/YY):

Address:

City/Zip:

Phone:

Email:

Global Health True Leaders 2016

Application Form
DEADLINE: MAY 8, 2016
Fax:

Website:

Briefly describe your position and responsibilities:

SECTION 5: ORGANIZATIONAL EXPERIENCES

Please describe any organizational experience that you have been involved, including: working experience,
internship experience, volunteer organizations, community associations, or similar:
Organisation

Year

Position Held

CIMSA UNAND

2014- Now

Project Team CIMSA Unand

CIMSA NASTIONAL

2015-2016

HRD Team

Description of Involvement

Global Health True Leaders 2016

Application Form
DEADLINE: MAY 8, 2016
SECTION 6: SCHOLARSHIP AND AWARDS
Please detail any scholarships, academic awards, bursaries, prizes you have obtained.

Global Health True Leaders 2016

Application Form
DEADLINE: MAY 8, 2016
SECTION 7: TRAINING AND WORKSHOP
Please indicate any training and workshops you have attended in last 3 years.
Name of Training or Workshop

SECTION 8: LANGUAGES
How would you describe your English and/or other Languages skills? (1=poor; 5=excellent)
Language
Years studied
Speaking (1-5) Reading (1-5) Writing (1-5)
7
4
4
4
English

Year

Global Health True Leaders 2016

Application Form
DEADLINE: MAY 8, 2016
SECTION 9: SHORT ANSWER QUESTIONS
Please answer the following questions to the best of your ability.
1. Please describe your motivation to participate and the experience that you hope to gain in Global
Health True Leaders. (in 1 paragraph)

2. Please describe your personal definition of Leadership, the qualities to be a good leader (please give an
example), and your experience in leadership. (in 1-2 paragraph)

3. Please describe your future plan in five years. (in 1 paragraph)

Global Health True Leaders 2016

Scholarship Form
DEADLINE: MAY 8, 2016
Please Note:
1. This scholarship is awarded to Global Health True Leaders participants in order to attending the
training. Please complete the information in application form and email to the nco@indohun.org.
If selected, you will receive a confirmation letter.
2. More than 150 scholarships are available for Global Health True Leaders participants.
3. The detail of scholarship package below.
Scholarship
Gold
Platinum

Scholarship is include
Accommodation, Training fee, Field Work fee, Field Leadership Fee, City Tour fee,
Training Kit, Training Materials, Meals, and Gala Dinner
Transportation by airplane, Accommodation, Training fee, Field Work fee, Field
Leadership Fee, City Tour fee, Training Kit, Training Materials, Meals, and Gala Dinner

Please answer the questions

Name of Applicants: ____________________________________________________________________

Occupation: ________________________________
Company/Faculty: __________________________

Study background: _____________________

GPA: ___________

Please indicate the amount you are able to pay:___________________

Important:
It is your responsibility as applicant to submit the PDF which including Application form, Health Certificate,
English Proficiency, Police Clearance Report, Identity Card, and Photo in one file (in format: GHTL 2016_Your
Name_Your Institutions_Your Current Domicile.pdf). If selected, we will publish the announcement of Global
Health True Leaders candidates on www.indohun.org on May 15, 2016 and you will receive a confirmation
letter. Please fill the confirmation letter and send it to INDOHUN email due to July 1, 2016. You will be an
official participant of Global Health True Leaders once you received the official invitation letter.

Global Health True Leaders 2016

REQUIREMENTS AND RULES
DEADLINE: MAY 8, 2016
1. There are 6 required files that you must be submitted to register yourself to be Global
Health True Leader participant.
Application form
There are 8 sections included. Each section contains questions which must be completed
with straightforward and factual answer. These include those that enquire about your
personal details, interests, educational background, and other related to GHTL. More than
150 scholarship will be awarded to several qualified applicant. Scholarship will cover all
the training costs, including accommodation and transportation fees.
Health certificate
Health certificate is a result of medical examination to describe condition a person has,
such as allergic or sickness. It can be obtained in hospital or health center.
English proficiency
It can be a valid TOEFL, IELTS, TOEIC score, least is a TOEFL prediction score.
Police clearance report
An official document issued by the police or government agency of a country as a result
of a background check to enumerate any criminal records that the applicant may have. In
Indonesia, it is known as SKCK (Surat Keterangan Catatan Kepolisian). You have to submit
the valid one.
Identity card
The identity card can be residential identity card, student identity card, driver license, or
passport.
Photo
Your photo must be a half body formal photo with white background and clearly seen face.
The photo size is 4x6.
2. All the required files must be completed and submitted to nco@indohun.org with subject
[GHTL 2016 Application] Name_Domicile(province) no more than May 8, 2016.
Uncompleted files and submission after the deadline will not be proceed. All files must be
merged into one file (PDF) with the format name:
3. We will announce the selected applicant on website www.indohun.org on May 15, 2016
and send the confirmation letter to all candidates. Please complete the confirmation letter
and send it back to nco@indohun.org due to July 1, 2016.
4. You are officially being a participant once you received the official invitation letter from
INDOHUN.
5. Global Health True Leader participants will be divided into three regions (Padang,
Kupang, Bali) by INDOHUNs team through some considerations. The placement decision
is absolute.