Global Learning Opportunities Scholarship: Application Form

1. School of Healthcare Sciences/Ysgol Gwyddorau Gofal Iechyd
Global Learning Opportunity (GLO) Scholarship Application Form
GLO Scholarship Application Form January 2015 Page 1
Instructions: complete electronically by the specified deadline and e-mail to
HCAREInternationalEnquiries@cardiff.ac.uk Late entries cannot be accepted
Section 1: Personal Details - Please provide details as requested in the spaces below.
The information will be treated in the strictest confidence.
Student ID Programme Cohort
First Name Surname
Correspondence
Address:
Home address if
different
Mobile phone
number:
Email Cardiff &
Private
Section 2:- Details of the Global Learning Opportunity
Please provide details as requested in the spaces below
Name of
Hospital/Institution/
Organisation
Address of Hospital/
Institution/ Organisation
Name of Contact Person
Address of Contact Person
Contact: Tel No: Email:
Duration of Global
Learning
Opportunity(specify dates)
From: To:
If you are undertaking the
placement with another
Healthcare Sciences
student, please state their
details
Name student and ID:
Programme of Study:
Cardiff Email:
Private Email:
Mobile number:
If you are undertaking the
placement with students
from other universities,
please give their details
Name of student and ID:
University:
Programme of Study:
University Email:
Private Email:
Mobile number:

2. School of Healthcare Sciences/Ysgol Gwyddorau Gofal Iechyd
Global Learning Opportunity (GLO) Scholarship Application Form
GLO Scholarship Application Form January 2015 Page 2
What is the estimated cost of your placement?
Travel-
Accommodation-
Subsistence-
Total Estimated Costs -
Have you received funding from any other sources? No/Yes, If yes specify
Amount awarded:
Name and contact of the organisation/person:
Have you/or your group undertaken any fundraising
activities to support your GLO?
No/Yes, If yes specify
Amount raised:
Activities undertaken:
Have you received funding from HCARE previously? No/Yes, if yes please specify
Amount awarded:
Purpose for the award:
Section 3:- Global Learning Opportunity proposal
Address the following 5 points using no more than 1000 words in total.
1. State how this opportunity will help broaden your knowledge and understanding of healthcare organisation and
delivery;
2. State how you intend to prepare yourself for this visit;
3. State how you will uphold the reputation of the University whilst on this Global Learning Opportunity;
4. State your academic and clinical progress to date;
5. State your participation in citizenship for the School of Healthcare Sciences and the University.

3. School of Healthcare Sciences/Ysgol Gwyddorau Gofal Iechyd
Global Learning Opportunity (GLO) Scholarship Application Form
GLO Scholarship Application Form January 2015 Page 3
Section 4: Overseas Placement preparation
Please indicate either the YES or NO option by placing an X alongside each row
YES NO
You have considered the CU overseas travel guidance information
https://intranet.cardiff.ac.uk/students/your-study/spend-time-abroad/stay-safe-
abroad l
You have considered the Foreign Office travel guidance information
https://www.gov.uk/knowbeforeyougo
You will arrange travel and accommodation
You will arrange insurance
You have discussed this application with your Personal Tutor and had it agreed in principle
You have requested a reference from your Personal Tutor

4. School of Healthcare Sciences/Ysgol Gwyddorau Gofal Iechyd
Global Learning Opportunity (GLO) Scholarship Application Form
GLO Scholarship Application Form January 2015 Page 4
Section 5: Student Declaration:
I declare that all the information I have given in all parts of this form and my application are correct and complete as far
as I am prepared to divulge.
I agree that I am solely responsible for all consequences arising from any relevant information that I have withheld.
I declare that I have considered and acted upon any Foreign Office/Cardiff University/host organisation’s travel
guidance.
I will continue to monitor the Foreign Office travel guidance and if I have any concerns regarding my health and safety
prior to, or during my GLO, I will inform HCARE immediately:- HCAREInternationalEnquiries@cardiff.ac.uk
I agree to inform HCARE immediately if for some reason I am unable to participate in the planned GLO.
I understand that my individual case will be considered by the bursary panel and any funding received may need to be
repaid (eg in the event I withdraw from the proposed activity).
I agree to act as an ambassador for Cardiff University and HCARE both during and after my GLO particularly assisting in
promoting global learning opportunities on my return to the University.
I agree to submit a report about the GLO (approximately 1000 words) within 4 weeks of my return.
I agree to the School of Healthcare Sciences utilising my GLO experience for marketing purposes YES/NO
Student signature: (A typed signature will be accepted) Date:
Please provide Name of Personal Tutor:
Please complete electronically, sign the declaration and email together with your reference to:-
HCAREInternationalEnquiries@cardiff.ac.uk

5. School of Healthcare Sciences/Ysgol Gwyddorau Gofal Iechyd
Global Learning Opportunity (GLO) Scholarship Application Form
GLO Scholarship Application Form January 2015 Page 5
School use only
Section 6: Assessment Criteria for GLO Application
Any actions Outcomes
Approved by : Date:
Personal tutor reference requested : Yes/ No
Assessment score for scholarship (total out of )