7TH INTERNATIONAL NURSING SUMMER SCHOOL 2021

School of Nursing Activities

Faculty of Medicine and Health Science
Universitas Muhammadiyah Yogyakarta
Email : umy.inss@gmail.com
Website : inss.umy.ac.id
Phone number : ( 0274 )387 656. Ext. 215.
Fax ( 0274 ) 387 658

STUDENT APPLICATION FORM 7TH INSS 2021

This year INSS will be running from July 13rd-24th 2021
Application Deadline July 28th 2021
All students seeking to apply for 7th INSS 2021 must complete this form in it’s entirely

PERSONAL DETAILS
Last Name : EFFENDI Instant Messenger : WhatsApp
First Name : MEGA PUTRI Preferred Method of Contact: Phone
Sex : female University : Universitas Muhammadiyah
Birthday : october, 02 2002 Lamongan
Nationality: Indonesia School Attended:
Address : Ketapang telu Nursing
karangbinangun Lamongan 002/001
Home Number : +62 857-3087-0209
Mobile Number : +62 857-3087-0209
ID LINE :
Email Address :
megaputri4471@gmail.com

EMERGENCY CONTACT DETAILS

Last Name : Effendi
First Name :. Sunhaji
Contact Number :
Relationship : Father
MEDICAL INFORMATION
Date of last tetanus immunization: -
Is there any other immunization you have taken? No
Student Medicare: Healthy
Private Health Insurance: no
Do you have any medical conditions? No
7th INSS 2021 SURVEY
How do you rate your knowledge in the field of nursing summer school?
I’m a Beginner
*If you check one of the boxes with this (*) sign, please state briefly why you rate
yourself in that level.
Because I’m in the secondary semester and I feel like in the basic level, so I’ve to study more
about my preferences in nursing.

How did you hear about 7th INSS 2021? (You can sign more than one checkbox)
[ ] Others, please specify (From Lecturer of Nursimg major)

MOTIVATION AND EXPECTED OUTCOMES

Motivation letter to join in 7th INSS 2021:
I hope after attending this event, can be a driving promoter in this generation

Date: June, 23 2021

Signature: MEGA PUTRI EFFENDI

Please write clearly and print this form after you fill in its entirety, and sign it
with written signature.
Send a color scanned document and evidence of
transfer of this form to: himikaumy01@gmail.com
For more information you can also send us via WhatsApp :
Filia: +62 823-2946-0087 (Liaison Officer)
Rofiq: +62 822-4916-3090 (Liaison Officer)