FATIMA MEMORIAL SYSTEM, SHADMAN, LAHORE
A member of Fatima Memorial System Fatima Memorial Hospital, FMH College of Medicine and Dentistry, Saida Waheed FMH College of Nursing, FMH College of Postgraduate Medicine, FMH Institute of Allied Health Sciences, Nur Foundation Community Outreach Program UAN: +92 42 111 555 600, Fax: +92 42 7570586, Website: www.fmsystem.org
NUR STUDENT LEADERSHIP PROGRAM (NSLP) APPLICATION FORM Instructions 1. 2. 3. 4. 5. 6.
SLP is open for all students of O Levels, A-Levels/Intermediate and above. It is not restricted to pre-medical students Please complete all sections and attach any additional information, if required Your application and personal information will be kept confidential Use CAPITAL LETTERS throughout Use black / blue ink only for filling the form Incomplete form will not be accepted
Section: I (Personal Information) Name: __________________________________________________________________________ Father’s / Mother’s Name: _________________________________________________________
Passport Size Photograph
Father’s / Mother’s Occupation_____________________________________________________ Gender: Date of Birth:
Male
Female -
Nationality: ________________ -
Permanent Address: __________________________________________________________________________________ Land Line No.: __________________ Mobile Phone: _____________________________________ Present Address: __________________________________________________________________________________ Contact: ____________________________E-Mail: _______________________________________ In case of emergency person to be contacted: Name: _________________________Relationship: ___________Contact#________________________ Mailing Address: _______________________________________________________________________________________ Section: II (Academic record / achievements)
Current Class: ______________________Current School/College/University______________________________
Qualification
Name of Institution
Year
Marks Obtained
Total Marks
Grade / Division
Major Subject
If you have any academic / non academic achievements, awards or honors, please provide details below: Sr. #:
Award / Achievement / Honor
Subject / Field
Year
Class
Institution
1. 2. 3.
Section: III (Please mark your desired profession): If you intend to pursue a medical profession, please specify your preference:
MBBS
BDS
Allied Health Sciences
Section: IV (previous internship detail) Have you attended internship at Fatima Memorial System?
Yes
No
If you have attended internship at any other institution, please provide details below Sr. #
Organization / Institution
Year
Session
Duration From
To
Specialty
1. 2. 3.
Section: V (References) How did you find out about internship at FMH? Through your Institution
Through a friend
Through our website
Any Other__________________________________________________________________________________ Section: VI (Your Talents) At the end of Internship we arrange a closing ceremony, please specify your talents which we can utilize at that occasion: Musical Instrument (specify) ___________________
Organizing
Drama / Acting
Stage Decoration
Photography
Script Writing
Video Capturing
Make Up
Compering
Art Work / Painting
Singing
Any Other__________________
Section: VII (The Schedule)
INTERNSHIP OPTIONS Please select from any one of the options enlisted below for which you are eligible OPTION1: 2 WEEKS Only open to 0 & A-levels / Intermediate /American High School Diploma Students
10th June- 22nd June 24th June – 05th July 08th July – 19th July 22nd July – 02nd August
OPTION 2: 4 WEEKS Only open to O & A-levels / Intermediate/American High School Diploma/ Bachelors Degree Students
24th June- 19th July
Core Skills Preference Please select any 3 from the following and enlist them in order of preference. We will try and place you in your selected courses depending on the availability of seats in that course. You are encouraged to submit at the earliest to ensure your registration in your preferred course Please write 1,2, and 3 in the boxes with core skills according to preference in following order Preference: (1= most, 2= more, 3= least) Advocacy & Skills Enhancement Core Skills 1: Innovation Studies Core Skills 2: Journalism & Article Writing Core Skills 3: Shadowing Doctors Program Core Skills 4: Fundraising & Resource Utilization Core Skills 5: Public Speaking & Dramatic Arts Core Skills 6: Environmental Stewardship & Management Informational & Vocational Training Core Skills 7: Photography Foundation Core Skills 8: Introduction to Music Production- Guitar Core Skills 9: Art & Design Core Skills 10: Computer Studies and ICT Academic Modules Core Skills 11: SAT/ACT Preparation Core Skills 12: International Science Ordinary Level Core Skills 13: Islamiat (2058) Core Skills 14: Pakistan Studies (2059) Core Skills 15: Economics (2281) Core Skills 16: Physics (5054) Core Skills 17: Chemistry (5070) Core Skills 18: Biology (5090) Core Skills 19: Mathematics D (Calculator Version) (4024) Core Skills 20: Additional Mathematics (4037) Advanced Level
Core Skills 21: Biology (9700) Core Skills 22: Chemistry (9701) Core Skills 23: Physics (9702) Core Skills 24: Mathematics (9709) Core Skills 25: Economics (9708)
Note: The Internship Duration is 4 weeks. Academic modules will continue after the end of internship. You will be required to register for the ongoing academic sessions after the internship. Details available with the NSLP Office.
OPTION 3: 4/6 WEEKS Only open to students enrolled in Bachelor and Master Degree
10th June –19th July 22nd July- 30th Aug
Please select one from the following for 100 hours (Bachelor and Master Degree)
Community Work Administration
Food & Nutrition Services HR
Psychiatry
Research
Microbiology
Dentistry
Signature of Parents: _________________________
Date: ____________________
Signature of Principal: _______________________ or Administrator
Date: ____________________
Section: VIII (Declaration) I hereby declare that the statements made by me in this form are true and correct to the best of my knowledge. I understand that I will be held liable for any material misrepresentation, omission made thereon or any other document requested by or submitted to the Organization. I also undertake that I will abide by the rules & regulations of the Fatima Memorial System and will not participate in any unlawful activities at FMS.
Please submit this form latest by May 25th, 2013 to:
Applicant’s Signature:
Nur Student Leadership Program
Internship Office Room # 1, 4th Floor, College Building Fatima Memorial Hospital, Shadman, lahore-54000 Cell : 0332-8417563 – 0332-8417564 Land line : (042) 111-555-600 Ext : 390 Email : internship@fmsystem.org nslp@nurfoundation.org
_______________________
Date: ____________________ 1. Please note while we will try to accommodate you as per your preference, we cannot guarantee availability of seats in the preferred time slots