0 Booking Your Clinical Placement Section 1 | Location and DatesWhere would you like to go?*Moshi, TanzaniaJohannesburg, South Africa General information about this clinical placement location: This location is suited to paramedics, critical care medics and doctors. The cost of this location is higher than that of all the other locations we offer. This is due to the time slots being extremely limited. We recommend you choose this location if you want to be able to add some flight medic experience to your CV. This placement offers a unique opportunity to do so. Cost is € 700 for four days. A deposit of 300 euro (non-refundable) secures this clinical placement opportunity. Payment of the remainder will be due two weeks in advance of the placement. Special considerations for this clinical placement location: This placement can be attended only if a 'certificate of good standing' or similar background check can be supplied by the applicant in advance of attending the placement. Due to hot summertime temperatures (affecting the helicopter's capacity to carry weight), no observers can be taken on the helicopters between 01. June and 31. August. I would like to book the following time slot:*(You can choose more than one. - Each four-day time slot costs 700 euro. ) (none available at the moment) I would like to start the placement on or around the following date...* Date Format: DD slash MM slash YYYY I would like to end the placement on or around the following date...* Date Format: DD slash MM slash YYYY Flexibility with these dates:*(You can choose more than one.) Ideally, none: Please check if these will work. None: I only have those dates available. A few days either side. I would also consider a different time frame if this one is difficult to schedule. I would like to break up my clinical placement into several shorter time frames. You can give additional details about your schedule preferences here:You have the option of booking a day in the Cadaver Lab.... Or two or three days, or even more...I want to book one day at an additional cost of €800.I want to book two days at an additional cost of €1600.I want to book three days at an additional cost of €2400.Are you currently enrolled in CoROM's diploma programme?*Yes, I am.No. Section 2 | Personal DetailsName* First Last Address*(We need your address for issuing an invoice.) Street Address Address Line 2 City County / State / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Age Group?*18 - 2425 - 2930 - 3435 - 3940 - 4445 - 4950 - 5455 - 59The helicopter pilot will need to know your weight.*Please choose an approximate value from this list.55 kg (121.3lb.)60 kg (132.3lb.)65 kg (143.3lb.)70 kg (154.4lb.)75 kg (165.4lb.)80 kg (176.4lb.)85 kg (187.4lb.)90 kg (198.5lb.)95 kg (209.5lb.)100 kg (220.5lb.)105 kg (231.5lb.)110 kg (242.6lb.)115 kg (253.6lb.)Email Address* Section 3 | Required Documents All the below documentation is required. You can, however, submit it at a later time, by email. Upload your CV Drop files here or Upload a picture (or a scan) of your passport. Drop files here or Upload proof of your medical qualification. Drop files here or ... One more thing: This particular placement can be attended only if a 'certificate of good standing' or similar background check can be supplied by the applicant in advance of attending the placement. You may upload it here in case you already have one. As this kind of document (often called a police certificate) is handled differently from country to country, we have no guidelines to offer on this. - We will pass it on to the manager of HAA, and he will then either approve it or give more guidance on what he requires. Drop files here or Section 4 | Liability Waiver and Healthcare StatementsSection 3 | Liability Waiver and Healthcare Statements Here is some information that Hungarian Air Ambulance would like you to read carefully. Hungarian Air Ambulance Nonprofit Ltd. The role and duties of the Observer The Observer must keep on person a photo ID and the Observer Card issued by HAA during the shift. The Observer should report to the airbase 30 minutes prior to the shift start. Uniform: employees of HAA must wear the official flight clothing while on observer shift. External Observers should have their clothing assessed by the Base Manager. Minimal requirements: boots or closed sturdy shoes long trousers (preferably not jeans) upper clothing with insignia (Ambulance, Rescue or similar) Clothing for Observers is not provided by HAA. Personal Protective Equipment including helmets as needed will be provided by HAA via the Base Manager or the Duty Crew of the day. Observers must comply with every instruction given by the Pilot In Command during the flight phase of the mission. They should also follow instructions given by the duty Doctor during the medical phase of the mission to the best of their knowledge. Observers must keep all operational information confidential. They must also comply with Hungarian regulations on patient’s rights for example regarding confidentiality. The duty Doctor has clinical responsibility during the mission. Observers can be involved in medical interventions based on their competence levels on request of the Duty Crew. During the mission, the Observer should follow basic and sensible Health and Safety rules. HAA can only be held responsible for aviation related incidents. HAA cannot be held responsible for workplace related incidents or accidents. Any filming or photography during the mission is subject to a written permit by the Managing Director. The Pilot in Command of the Duty Doctor has the right to terminate the observer shift with a justified reason. If for operational reasons the Observer has to find his/her own way back from scene to the Airbase, the Duty Crew will assist as much as they can. The Observer acknowledges to comply with every operational regulation of HAA. The Base Manager or the Duty Crew can help with the specific regulations. If the Observer does not speak Hungarian, HAA will make sure the Observer and the Duty Crew have a common language. Please confirm your willingness to comply:* I have read the information provided by Hungarian Air Ambulance and agree to comply with "The role and duties of the Observer". Clinical Placement Opportunities provided by the College of Remote and Offshore Medicine Foundation Healthcare Awareness Statement CoROM advise you to study the information published and updated by the World Health Organisation. (http://www.who.int/ith/en/) and by Centers for Disease Control and Prevention (https://wwwnc.cdc.gov/travel/destinations/list). You, the applicant, are responsible for keeping your vaccinations up to date and for arranging preventative measures against common travel health risks. Contact your doctor for advice if in any doubt.Please confirm:* I understand that it is my own responsibility to keep my vaccinations up to date, and to arrange preventative measures against common travel health risks for the country I am planning to visit for this clinical placement. Please also confirm:* I hereby confirm that I (either) already possess insurance cover that is appropriate to the clinical placement location I am booking today, (or) if I do not yet possess it, I hereby undertake to purchase appropriate insurance cover before travelling to my clinical placement destination. Clinical Placement Opportunities provided by the College of Remote and Offshore Medicine Foundation Liability Waiver You are preparing to attend a clinical placement provided by CoROM. During this time you will be operating in areas of risk. You may be exposed to risks of infection with communicable, air-borne and vector-borne diseases. You are responsible for your own safety, health care, health insurance, travel insurance and vaccinations during this time. You may also be operating in areas of unrest. You will be at risk while traveling for your placements. You will be at risk while working in various environments. You are required to be aware of your surroundings and your tactical situations. You are responsible for your own safety. By clicking on the “I understand the risks...” button below, you release and hold harmless CoROM, all parties employed by, and any organisation affiliated with CoROM for training and clinical placements. You acknowledge that CoROM cannot be held responsible for any costs or liabilities associated with these placements or any other risk or liability not covered in this statement. You understand that CoROM is solely a facilitor of this clinical placement opportunity.Please confirm:* I understand the risks described in the above Liability Waiver, and agree to proceed with my booking of this clinical placement. Section 5 | Finally...Section 4 | Finally...Is there anything else you would like us to know?Privacy* By using this form you agree with the storage and handling of your data by this website. * This iframe contains the logic required to handle Ajax powered Gravity Forms.