Request edit access
Summer School on Measuring Universal Health Coverage
June 26 -30, 2018
Organized by Indian Health Economics and Policy Association (IHEPA) in collaboration with Azim Premji University

For more information/clarification/technical problems, email: office.ihepa@gmail.com

Email address *
1. Full Name (as per Identity Card) *
2. Date of Birth *
MM
/
DD
/
YYYY
3. Sex *
4. Present address (for communication) with Pin Code *
5. Mobile number (10 digit) *
6. Occupation *
7. Full name of current organization (with location) *
8. Working professionals, please provide (i) your designation and (ii) Years of work experience (Others please mention "NA" in your response) *
9. Working professionals/students pursuing part-time M.Phil/Ph.D, please provide (i) full title of your research and (ii) University awarding the degree (Others please mention "NA" in your response) *
10. Full time registered M.Phil/Ph.D students, please provide the full title of your research (Others please mention "NA" in your response) *
11. M.Phil Degree awarded ? *
Discipline/specialization in M.Phil
Full name of the College/Department awarded M.Phil
Full name of the University (with location) awarded M.Phil
Year of passing M.Phil
Percentage/grade obtained in M.Phil
12. Degree obtained at Post Graduate level (M.A/M.Sc etc.) *
Discipline/specialization in Post Graduate degree *
Full name of College/Department awarded Post Graduate degree *
Full name of the University (with location) awarded Post Graduate degree *
Year of passing Post Graduate degree *
Percentage/grade obtained in Post Graduate degree *
13. Have you previously attended IHEPA Summer School/Conference? *
14. If attended earlier IHEPA (i) summer school/(ii) conference, mention which year? (Others mention "NA" in your response) *
15. Upload your structured research proposal in Microsoft Word Format (not more than 1000 words) - Mandatory for all *
Required
16. Do you require financial assistance? *
17. How will you benefit from this summer school? (100-200 words) *
18. Upload your latest publication(s), if any. (max. 2)
19. How did you hear about this course? *
20. Are you a MEMBER of Indian Health Economics and Policy Association? (To get membership, please go through the membership policy at IHEPA website/summer school brochure) *
I understand that I have provided all the necessary and correct information to the best of my knowledge, otherwise my application can be rejected at any time during selection process. *
Required
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Azim Premji University. - Terms of Service - Additional Terms