Application to Work / Visit C.O.U. Kisiizi Hospital

	Application to Work / Visit C.O.U. Kisiizi Hospital

You can download the application form from here and email to us.

Please fill in your details below.

To check availability for the dates you are considering [Calendar]. This information is updated monthly.

Please note all feilds marked with a '*' are mandatory.



Full Name:	*

Date of Birth:	*

Permanent Address:	*

Tel:	*

Email:	*

Confirm Email:	*

Marital Status:

Nationality:

Passport No:	*

Expiry Date:

Proposed Date of Visit:	Arrive: Depart:

Next of Kin:

Relationship:

Next of Kin Address:

Next of Kin Tel:

Next of Kin Email:

Confirm Next of Kin Email:

Organisation / Training Institution:

Organisation Address:

Professional Referee:

Prof Ref Tel No:

Prof Ref Email:

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?

Home Church:

Do you have any important medical problems?	If YES, please list:

Are you taking any medication?	If YES, please list:

Any special dietary needs / Allergies?	If YES, please list:

I confirm that I have downloaded and read the Information Sheets and Guidelines for visiting Kisiizi available off the Website : Yes I have downloaded and read the information No, I have not


C.O.U. Kisiizi Hospital, PO Box 109, Kabale, Uganda. Email: kisiizihospital@yahoo.com Tel: +256 392 700806 (+3hrs GMT) Office hours only Please check potential availability for electives by visiting the calendar before applying.