Application form for Incoming Students

Health Sciences

Personal Data Given name   Family name   Date of birth   Gender   Male Female Citizenship   Current Address Valid from   Valid to   C/O (name on the door if it is different from your own name)  Address   Postal code   City   Country   Email   Mobile phone (incl. country code)   Permanent address (if different from current address) (Always valid - for example parents' address) Name on the door  Address  Postal code  City  Country  Academic Data Sending institution   Study programme   Midwifery Nursing Occupational Therapy Physiotherapy Radiography Other Number of years of study prior to studying abroad   1 2 3 4 Coordinator/contact person at sending institution (incl. phone and email)   Period of study at University College of Northern Denmark Which period are you applying for at UCN - semester:   Spring Autumn Type of module   Clinical Theoretical Clinical and Theoretical First day of study at UCN   Last day of study at UCN   Exchange programme   Erasmus Nordplus Free mover Other If other - please specify  Accomodation Need of accomodation   Yes - I need accomodation No - I do not need accomodation If yes - please state period From  To  Contact information in case of emergency This information will be used by UCN in case an emergency situation takes place once you are in Denmark. Relation (mother. father etc.)   Full name   Address   Telephone number (incl. country code)   Do you agree to UCN making your contact information (name, e-mail, and mobile no.) available to other exchange students on a list of exchange students?   Yes No Please check the information carefully before clicking on "Send" to continue. A copy of your application will be send to your e-mail. Date of application