APPLICATION FORM Academic Year 2024/2025

Undergraduate Students Universitas Pelita Harapan

Faculty of Medicine Application Form

Form Number :
#2451102456
Kode Registrasi
Full Name :
Nama Lengkap CHARLENE ALISSA NDOLU

Name of Family Doctor :

Nama Dokter Keluarga Dr. EIRENE ATE

NO ADDITIONAL REQUIREMENTS FOR FACULTY OF MEDICINE

1 Color Blindness Test Certificate by Ophthalmologist / Oculist

2 A 500 word English Essay about “Why I am Interested in Medicine and How I Will Use It to Provide Good Health Care for the People of Indonesia in the
Future.”
3 2 Recent Photos (size 3x4) in white collared shirt with blue background

COMMUNITY INVOLVEMENT

Please provide a brief summary of all volunteering, caring, community leadership, religious services and organizations that you have
participated in.
Jelaskan secara singkat semua bentuk partisipasi Anda pada kegiatan relawan, kepemimpinan, pelayanan keagamaan dan organisasi.

Hi, my name is Charlene Alissa Ndolu and I usually go by Alissa. I am currently 17 years old. Actually, I have no experience in
volunteering and leadership activities, but I do have experience in religious service. I was 15 years old when I took catechism classes for a
year. During this year I am usually used for religious activities, such as at Easter, I act in dramas to fill sermons or reflections, sing to fill
liturgy services, in cultural months I usually dance traditional dances to fill church liturgy, and in October school basic November 2022 I
will provide services in homes. When I was in middle school, I also participated in a scout organization.

PERSONAL ACHIEVEMENT
Please provide a brief summary of your current sports, artistic activities, hobbies, and interests.
Jelaskan secara singkat tentang kegiatan olahraga, seni, hobi, dan minat Anda saat ini.

I really like singing, it is my hobby. When I was little, I often sang in the prayer room or what is usually called a fellowship, I also sang at
school for the 12th grade arts event. When I had free time, I usually did karaoke and sang and listened to songs for quite a long time. Apart
from singing and listening to music, I also like dancing. When I was in kindergarten, I represented my kindergarten in a group dance
competition and won third place. I have also been a tambourine dancer and also danced traditionally in church to fill cultural events during
cultural month at the church. Apart from that, I also like reading novels, one of my favorite novels is "Circus Tree" by Andrea Hirata.
When it comes to sports, I don't like that field, but I like watching football and futsal. I also joined the school drumband in elementary and
high school, if there was a carnival or other event that required a drumband group, I always played drums and tenor.

By signing this form, I agree to abide by the regulations stated by Faculty of Medicine, both now and in the future. This includes all activities and
examination that may be held outside of Monday to Friday.
Dengan menandatangani formulir ini, saya bersedia menaati peraturan yang telah diberlakukan dan akan diberlakukan oleh Fakultas
Kedokteran. Hal ini mencakup semua kegiatan dan ujian yang mungkin diadakan diluar hari Senin hingga Jumat.

Prospective Student,
Calon Mahasiswa

,
Place | Tempat Date | Tanggal
potong

Prospective Student’s Signature & Full Name

Tanda Tangan & Nama Lengkap Calon Mahasiswa

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