Membership Application Form

Thank you for showing interest in the S.S.S. For checking our mission statement & goals, please check the relevant web page. We would appreciate your honesty in filling this form; the info you provide in this form will help us to get to know you better, & will be of crucial importance for the recruitment process.

Please note carefully the following:

· Online application forms will be the only forms available.

· All the following fields are required. Application forms will be considered invalid if submitted missing any one of these fields.

· Any application form sent after the deadline specified will be considered invalid.

· In case you submitted a valid application form, an invitation to the interview, including the day and the timing, will be sent to you by email.

· Please do your best to be on time on the day of the interview, it might be very difficult to find an alternative timing. In case you missed the interview, the application will be considered invalid.

· You can always re-apply at any time :)

For the July 2010 recruitment campaign:

Applications will accepted from all the student years . ALL applications sent before 26 July 2010 will be considered valid

Contact & personal details

Full Name:
Gender:	Male Female
Date of Birth:	Day:  1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month:  1 2 3 4 5 6 7 8 9 10 11 12 Year:  1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011
Year of study:	First Second Third Fourth Fifth Sixth   Year
Nationality: (if more than one, please mention all)
Address:
Email address:
Mobile phone No.:
Home phone No. (Optional):

Educational details

High school:
Have you attended any training(s) or course(s) (medical or non-medical) before?	Yes
If yes please name:

Interests

How did you hear about the S.S.S.?

What do you expect to gain from the experience of joining the S.S.S.?

Which of these activities are more appealing to you? (At least specify one) Health awareness Organizing events Writing in S.S.S. magazines Web design Graphic design Fundraising Exchange program (Incoming division) Social activities Exchange program (Outgoing division) Public relations

Have you ever shared in any extracurricular activities, volunteer work, sports team or any sort of team-work involvement? If so, please name.

Please share with us (in a paragraph) what has this experience added to you, especially the skills/interests that you would like to use in the S.S.S.

Spoken languages

Please note that for languages other than English, a proof may be required. e.g.: A certificate

English FluentVery GoodGoodFairNone

French FluentVery GoodGoodFairNone

German FluentVery GoodGoodFairNone

Other (Please specify)

		FluentVery GoodGoodFairNone
		FluentVery GoodGoodFairNone

Previous travel experience

Countries visited	Aim of visit
Albania Algeria American Samoa Andorra Angola Anguilla Antigua Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Barbuda Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Botswana Brazil British Virgin isl. Brunei Bulgaria Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Rep. Chad Channel Islands Chile China Colombia Congo Cook Islands Costa Rica Croatia Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Faeroe Islands Fiji Finland France French Guiana French Polynesia Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guinea Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Irak Iran Ireland Ireland, Northern Italy Ivory Coast Jamaica Japan Jordan Kazakhstan Kenya Kuwait Kyrgyzstan Latvia Lebanon Liberia Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mexico Micronesia Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar/Burma Namibia Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Norway Oman Palau Panama Papua New Guinea Paraguay Peru Philippines Poland Portugal Puerto Rico Qatar Reunion Rwanda Saba Saipan Saudi Arabia Scotland Senegal Seychelles Sierra Leone Singapore Slovak Republic Slovenia South Africa South Korea Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Taiwan Tanzania Thailand Togo Trinidad-Tobago Tunisia Turkey Turkmenistan United Arab Emirates U.S. Virgin Islands U.S.A. Uganda United Kingdom Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wales Yemen Zaire Zambia Zimbabwe	Education Tourism Work Other
* hold ctrl button for multiple selection.

Skills

Do you have experience in any of the following?

Communication skills ExcellentFairNo, but I'd love to learn

Leadership skills ExcellentFairNo, but I'd love to learn

Time management skills ExcellentFairNo, but I'd love to learn

Crisis management skills ExcellentFairNo, but I'd love to learn

Web designing skills ExcellentFairNo, but I'd love to learn

Graphic (Photoshop or any similar program) designing skills ExcellentFairNo, but I'd love to learn

Writing & editing skills ExcellentFairNo, but I'd love to learn

Creative thinking ExcellentFairNo, but I'd love to learn

*If you have previous experience in graphic design, writing or editing, please bring us samples of your work to the interview.

Have you shared in any training or soft-skills course in any of the previous? If so, please name.

Please evaluate yourself from 5 to 1 (given that 5 is best and 1 is least) in each of the following qualities/personality traits:

Comfortable following rules, procedures & regulations 12345

Acceptance of other's cultures & beliefs 12345

Objectivity 12345

Flexibility to change & eagerness for new experiences 12345

Enthusiasm 12345

Willingness to assume responsibilities 12345

Availability 

(Please note that there is no ‘Right Answer’ for questions in this field, they shall not affect the selection process by any means, but will be of utmost importance for the recruitment process)

About how many hours per week you will be able to commit to the S.S.S.?      

Which days of the week are best to contact you?
(Please note that any amount of time you give is valuable to us, be it an hour every now and then or a regular commitment.)

Saturday Friday Sunday Monday Tuesday Wednesday Thursday

* hold ctrl button for multiple selection.

How often do you check your email?  

In your point of view, what do you think is the role of students’ organizations in the development and improvement of medical education and public health in Egypt?

Is there any thing else about you that you would like to share with us?

For any inquiries please contact:
Ashraf Mostafa Mahrous
S.S.S. Acting Vice President for Internal Affairs.
Mobile Phone: 0105395235,0101606449
Email:ashraf.mahrous99@gmail.com,amani.a7med@gmail.com