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APPLICATION FORM BALI INTERNATIONAL SUMMER SCHOOL 2013

Personal Details Family Name First Name Nick Name Date of Birth Gender University
Current Academic Year

:Muhammad :Azmi :Agung : 4th Otober, 1991 :Male :Malikussaleh University, Lhokseumawe :2010 :Jl Rel Kereta Api Cunda, Lhokseumawe :Lhokseumawe / Aceh : :Indonesia :085296895459 :azmiagung@gmail.com

Address City/ Province ZIP Code/ Postal Code Country Telephone Number E-mail Below are optional Facebook Twitter Skype Yahoo Messenger Other Messenger

: agungazmi :azmiagung : : :whatsup 08975606980

Medical Information Past History of Illness (Such as allergy) :NO YES If yes, please mention it :

Other Important
Are you vegetarian or not : a. Vegetarian
Consideration of Your Food

b. Non-Vegetarian

MOTIVATION AND EXPECTED OUTCOMES

Motivation letter:
Dear Organizer Committee, I am writing this letter to express my aspiration to participate in Bali Summer School 2013. My name is Muhammad Azmi Agung. I am a third year of medical student in Malikussaleh University. While at school, I learned the importance of being independent in a field I am passionate about. I tried to join some extracurriculars and to take several times where I can upgrade knowledge. My faculty including one of the beginner among other medical of schools in Indonesia. It is in Aceh, One of the province in Indonesia. It is welknown of its beach, unique cultures, white-coral sand, forests, animals, and also some stories behind that. I have discovered to visit some of that place through the social activity which is held by campus regularly. They are still natural. However, we also find some problems for making vacation. Infectious disease, harmful sunray ( it also related global warming ), hygiene food, safe travelling and many others. For example in Sabang Island which is welknown of its wonderful beach is an endemic malaria. Therefore, as a medical student, i am highly motivated to participate to discuss in solving that kind of problems related to the Travel Medicine such as knowing earlier about the description of disease, preventive, and also the treatment. I was interested to the international event such a summer school which is presented all students whole over the world. I hope the outcomes can be a self reminder for me to try contributing and sharing to others in order that can be applied in Indonesia and Aceh it self.

I have completed the given application form and have verified that all statements in this application are true and correct.
By submitting this application I agree with the Terms of Reference

*) Please attach: - Scan of Student IDs - Passport sized recent photo - All over body photo - Scan of passport (for Non-Indonesian citizens) - Essay about Travel Medicine (regulations and guidelines attached below)

**) After fully fill this form, please send back to us to : Email: balisummerschool@gmail.com

We'll contact you to your email as soon as possible. If you have any other question, please feel free contact us at: Email YM Twitter Skype : balisummerschool@gmail.com : bali.summerschool@yahoo.com : @BISS_2013 : bali_summerschool

Thank You

Regulations and Guidelines of Essay

1. Eligibility Condition Every candidate of Bali International Summer School 2013 participants must submit an essay as one of requirements to apply this program 2. Topic of The Essay Travel Medicine 3. Regulations of Writing The essay should be written in English (for all candidates) The essay contains facts and your own opinions about Travel Medicine Length of essay: 2-3 pages Format requirements: Typed on a A4 size electronic page Font: Times New Roman Font size: 12 points Line spacing: 1.5 lines 4. Essay Submission Requirements Submitted essays must meet all regulations of writing given above

All essays must be submitted as an e-mail attachment to balisummerschool@gmail.comaccompanied by the Application Form and other requirements which have been mentioned before