* = required field

*Name of Organization:
*Location (city, country):
Contact Person:
Title of Contact:
Address of Contact:
Phone of Contact:
Email of Contact:
Dates of your attendance:
Purpose of site institution (3-4 words):
Is there a language requirement? If so, state language:
Activities available (check all that apply):
patient care public/community health research clinical research
basic science research
Opportunities appropriate for (check all that apply):
preclinical students clinical students
other restrictions:
1. Please describe your activities while abroad (eg, seeing patients, clinical research, public health project, etc.):
2. Please describe the range of activities available, in addition to yours:
3. Would you recommend this institution to other Penn medical students? Why?
4. What did you not like?
5. Is there an application process for this institution? How does one arrange a visit? Are there important dates to know about?
6. What costs were associated with the trip, other than transportation. Please include institutional fees, housing costs, food, etc...
7. Did you receive funding for this trip? If so, from whom and for how much? Please provide important information, such as contacts, application procedure, and due dates:
8. Would you agree to be contacted by other students interested in this site? If so, please give your name and contact information:

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