UNC-CH Refugee Health Initiative

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Spring 2017 Participant Application

Name *

(first and last)

Gender *

Please indicate your gender orientation and/or expression as you identify. (This information will be used to pair you with a partner and family.)

Select your degree program *

Undergraduate

Graduate/Professional Schools

Doctoral

Major (Undergrads)/Program (Grad, Professionals, Doctoral) *

(i.e. Social Work, Public Health-Health Behavior, Med School, Biology major, etc.)

Email Address *

(The address you prefer to receive emails)

Because you will be visiting the home of your refugee family, do you have a car? *

Yes

Would you be willing to carpool or alternate turns driving to visit your family? *

Yes

N/A: I do not have a car

Although the majority of our families are based in Durham, Chapel Hill, and Carrboro, occasionally there may be a refugee family living in Raleigh in need of RHI services. This requires that you commit to slightly longer commute times to and from your family. Would you be willing to be matched with a Raleigh-based family? *

Yes

Do you have any experience with refugee populations? *

Yes

If yes, please explain in what capacity.

Please list any languages besides English that you can speak proficiently/conversationally. Please include levels of proficiency for each language. (I.e. Spanish-intermediate, Arabic-fluent, etc.)

Please provide a personal statement expanding on your interest in working with RHI. (1100 character limit) *

How much commitment do you expect to afford to RHI? How do you plan to maintain a consistent level of commitment throughout the entirety of the program? (1100 character limit) *

Please share any experience(s) you have had that have heightened your awareness of cultural differences. Can you provide a specific example of how you dealt with cultural differences in the past? (1600 character limit) *

If I become a part of the RHI team, I fully commit to the responsibilities I have to my refugee family as a participant and pledge not to leave the program until such responsibilities have been fulfilled. *

Please electronically sign your name.

I will attend the mandatory orientation. *

One or two orientations, which will take place in early February, will be announced by the last week of January at the latest. Exceptions will only be made if there is adequate evidence that proves you have class during both sessions. Do you agree to complete the mandatory orientation?

Yes

I understand that I must obtain a mandatory background check, for which I will pay approximately $25 out of pocket. I will have it completed in time to bring it to the orientation.

Yes

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