Personal details form- Summer Institute 2024

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Personal Details and Course Selection

First Name *

Last Name *

Email address *

What is the highest degree you have completed?

Affiliation (Professional, Academic Institution) *

Passport Number *

Name as it appears on passport *

Date of Birth *

Month

Day

Year

Country of Birth *

Mailing Address (Street, City, State/Province, Country, Postal Code) *

Are you a current student at Tel Aviv University or any other university in Israel? *

Yes

Additional Questions

Have you attended Summer Institute courses in the past? *

Yes

Why are you interested in participating in the Summer Institute? *

General interest in topic

Relevant to school or degree program (for credit)

Relevant to school or degree program (not for credit)

Relevant to job

Relevant to research

Course offered by prestigious university/professor

For personal growth and enrichment

To visit Israel

Other

Are you associated with: *

MECIDS

Zambia, Copperbelt University

A Tel Aviv University partner university

None of the above

Who is responsible for payments? *

Myself/Independently

Organization/Institution

PLEASE NOTE:

The Summer Institute is NOT responsible for arranging travel visas for international students. Please ensure that you have arranged all necessary permissions and travel documents, at least 1 month prior to arriving in Israel.

The Summer Institute does NOT provide meals or transportation, all participants must arrange for their own living expenses for the duration of their stay in Israel.

By submitting this form, I confirm that all the above information is complete and accurate.

I understand that this information will be saved securely by Tel Aviv University School of Public Health for purposes related to this program.

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