Kisiizi Hospital · Church of Uganda

Kisiizi Application Form

Please fill out this form to apply for an elective placement or volunteering visit.

“Life in all its fullness” — John 10:10

Application

Application type *

About you

Full name *

Date of birth *

Gender *

Permanent address *

Phone *

Email *

Marital status *

Nationality *

Travel

Passport no. *

Passport expiry date

Proposed date of arrival

Proposed date of departure

Next of kin

Name *

Relationship *

Address

Tel

Organisation & referee

Organisation / training institution

Organisation address

Referee name

Referee tel

Referee email

Your visit

What stage of training are you at?

How did you hear about Kisiizi?

What do you want to do at Kisiizi?

Do you have a personal Christian faith? *

yes

Home church

Documents

Passport copy *

CV *

Maximum 5MB per file.

I agree that the information and documents I have given here are used to process my application to Kisiizi Hospital. They are stored securely and are visible only to hospital administrators. *