Apply! Deadline: 11:59 pm on Wednesday, October 30, 2019 Program only offered to first year Geisel Medical students and TDI students Entries marked with * are required. Personal Information Legal Name*: (as it appears on your ID) Date of Birth*: Gender: Female Male Affiliation*: Medical Student TDI Student Address*: Email*: Cell phone*: What roles are you willing to be responsible for? Pre-Trip: Develop/Organize the Elective Develop Service Opportunities Organize Fundraising Coordinating Gifts Public Relations Budget Coordination Organize Fingerprinting/Background Checks During the Trip: Blogger/Public Relations Trip Leaders Photographers Expense Coodinator Post-Trip: Prepare Presentation to Medical School Community Coordinate Trip Report Send Thank You Cards Would you like your name added to the class roster for the MNIHST Elective?*: Yes NoPlease Note: You can only register for two electives at a time. If you are participating on the trip, you will still be required to attend all pre-trip sessions. Please answer the following questions Please describe your leadership or community service experiences and what you learned from them*: What have been your experiences with diverse cultures and languages?*: How can you contribute to this trip, would you be willing to help out with the planning process?*: Are you a certified Dartmouth College driver?*: Yes No If not would you be willing to become certified?: Yes No If you have any questions please contact Shawn O'Leary.