Institut et Haute Ecole de la Santé La Source Summer University Lausanne, Switzerland - Institut et Haute Ecole de la Santé La Source

«Disaster Readiness, Serene Awareness”

Dear Students,

We are pleased to welcome you at the Haute Ecole La Santé La Source from June 18th to July 07th 2023.

Your participation to the program is confirmed, but some information is still needed to complete our file. We need you to fill two forms. Before that read and sign the Individual Pledge, we need it back.

Deadline: June 01st 2023

Application form (below) & Individual Pledge (State of Vaud) to fill-in. If you cannot attach the documents requested at the end of the application form, you can send them by e-mail to Nadia Righetti at n.righetti@ecolelasource.ch
Flight details

We are looking forward to welcoming you in Lausanne!

Corinne Borloz, Dean of International Affairs. c.borloz@ecolelasource.ch

Nadia Righetti, Project ass. of International Affairs, n.righetti@ecolelasource.ch

SU Lausanne - Application form

Last (family name)*
First Name*
Middle Name
Gender*
- M
- F
Date of birth*
Passport number*
Passport - Date of issue*
JJ slash MM slash AAAA
Passport - Expiry Date*
JJ slash MM slash AAAA
Citizenship*
Permanent adress*
Zip code*
Town*
Country*
Mobile phone number*
E-mail*
Emergency contacts
Emergency contact*
Relationship*
Phone number*
Academic Information
Home University*
Year/Semester*
This program may be difficult for physically challenged people or people suffering from any illnesses. Do you suffer from any illnesses that require regular, specific treatment, or special needs?*
- Yes
- No
If yes, please specify:
Do you need a special diet?*
- Yes
- No
If yes, please specify:
Copy of your health insurance CERTIFICATE (please check with your insurance company that you will be fully covered for the visited country during the period of your stay.
Taille max. des fichiers : 293 MB.
Copy of your medical repatriation insurance CERTIFICATE
Taille max. des fichiers : 293 MB.
Copy of your passport
Taille max. des fichiers : 293 MB.
Individual pledge (filled-in)
Taille max. des fichiers : 293 MB.
I certify that above information is true and correct*
- Yes
Phone
Ce champ n’est utilisé qu’à des fins de validation et devrait rester inchangé.

«Disaster Readiness, Serene Awareness”

SU Lausanne - Application form

Emergency contacts

Academic Information