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	IHHR

UNSW Intensive Course on Health , Development and Human Rights

7 - 11 December 2009

Expression of Interest Form

NOTE: *denotes required field

General Information

Surname *

Given Name *

Title *

Gender *

Address Line 1 *

Address Line 2

City *

State *

Postcode *

Country *

Email address *

Re-confirm email address *

Phone number (incl. country code) *

Mobile phone number

Work Experience

Current professional title *

Current professional organisation *

Briefly describe your role *
150 words max

Briefly describe your previous professional experience in the health, development and/or human rights fields *
150 words max

Education and Language

Highest degree successfully completed *

If you selected Other please specify

Are you a current UNSW student? *

Yes No
What program are you enrolled in?
Student ID number

Are you a current postgraduate student at another university? *

Yes No
What program are you enrolled in?
What University are you enrolled in? (include city and country)
Do you intend to apply for cross-institutional enrolment?		Yes No

Is English your first language? *

Yes No
If No, please describe your ability to speak comprehend and write in English (Fluent, Intermediate or Beginner. Please feel free to include any English-as-a-second language examination results)

How do you intend to fund your participation in the course?

Current Interests

What are your current professional interests in the health, development and human rights fields? *
150 words max

Please indicate your primary interests in relation to this course's potential topics *
First area of interest *

		If you selected Other please specify

Second area of interest *

		If you selected Other please specify

Third area of interest *

		If you selected Other please specify

Referral

How did you hear about this course? *

Please add the details of the email list website of Other referral

Please check all information to ensure if it is correct and accurate.

• The UNSW Initiative for Health and Human Rights, • The University of New South Wales, • School of Public Health and Community Medicine, • Samuels Building, Level 2, • Sydney NSW 2052 Australia •
• T +61 (2) 9385 1071 • F +61 (2) 9385 1526 • E: ihhr@unsw.edu.au • CRICOS Provider Code 00098G
AUTHORISED BY Director, IHHR
Page last updated: Wednesday, June 17^th, 2009