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Expression of Interest Form
Fred Dietz Global Clubfoot Fellowship
Email address *
Name *
Job title *
Place of work *
Describe your current clinical practice with regard to treating clubfoot (maximum 250 words) *
How many clubfoot patients have you been the lead clinician for? *
Why are you applying for this Fellowship? (maximum 250 words) *
What are the top 3 things you are hoping to gain from the Fellowship? * *
Who is your sponsoring organisation or clinical reference? *
Please upload evidence to confirm their support (e.g. email, letter).
How would you ensure that you are able to cover any expenses you may incur during the Fellowship? *
Please can you tick yes or no to indicate the following *
I have valid clinical qualifications, and can provide evidence of these, and am in current practice treating clubfoot patients
I am currently fluent in English to communicate with clinicians and patients in an English-speaking setting
I have a clubfoot caseload of a minimum of 20 patients every year
I am available for at least one these dates: November 2019 / July 2020 to take part in this fellowship
I will be able to provide my clinical references to support my application
I will be able to cover any expenses incurred with this Fellowship (e.g. Visa, some contribution to subsistence, etc.)
I commit to fully participating in this programme, including everything necessary to get an Honorary Contract with the UK hospital trusts (e.g. being responsive to emails and any requests for information, coordinating your visa at least 3 months before the visit, etc.)
I agree to take part in the full Fellowship, including an evaluation
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