SUMMER ENRICHMENT PROGRAM

APPLICATION FORM

Date of Application : April 27th, 2011

Program of Interest : Anatomy dissection

Student Contact Information

Name : Daniel Gunawan Gender : Male

Email Address : Soccer_boyzzz@ymail.com

Home Address : Batutulis 18 No. 18D, Jakarta Pusat

Kost Address : Jl. Danau Poso No.28, Taman Beverly Golf, Karawaci, Tangerang

Telephone : Home : 021 351 2515

Mobile : 0817 6815 682

Parent / Legal Guardian Information

Name : Lie Ping Sen Email Address : nelsonlie@yahoo.com

Home Address : Batutulis 18 No. 18 D, Jakarta Pusat

Telephone : Home : 021 351 2515

Mobile : 0815 9968 650

Educational Background

Current year and semester in Faculty of Medicine : First year, Semester 2.

Current GPA (Grade Point Average ) : 3.76

Your Academic Advisors Name : F.X. Budhianto Suhadi

Telephone :

Professional Information

Extracurricular activities during University (include community and church)

I go to my church at GSJA Batutulis every Sunday and I actively serve there as musician
cause I can play keyboard and guitar. Not perfect, but its enough to be used for serving in my teen
community at my church. Im also planning to serve in TLC soon if they open a recruitment.
Ive just joined HELP for FK&FON as a volunteer since February and I have went to
Teluk naga twice. The first visit when we held low-price stuff bazaar and the second was to hold
Routine control for family in there.
How have you spent your previous summers?

I spent my previous summer mostly on helping my grandfathers tools shop in Glodok, Jakarta.
It started at 10am-3pm.

In the morning I usually went to Monas for cycling and playing basketball there. I could go to Monas
three times a week at that time.

Honestly, I didnt go on any trip during my summer holiday. For refreshing, I just went to mall
bookstore with my friends.

Please explain what qualities you bring to the Summer Placement Program

Ive learned in FMS2 about human anatomy, Ive also looked it up in atlas of human anatomy,
but it would be better if I know the exact location in human body. By joining summer program I hope it
can help me to know better about human anatomy as shown in new cadaver, which mean have
completely organ and easier to see.

All the above information provided is accurate .

Students Name ( Print ) : Daniel Gunawan (07120100042)

Student Signature :

Date : April 27th, 2011

Application Instructions : Please send the completed application, along with :

Letter of recommendation from your Block Coordinator and Current resume

All applications requirements should be submitted by mid- April for local organizations
and earlier for Overseas placements.

Thank you for your patienc e with this lengthy form. We strongly suggest you print this
page to retain as your record of what you submitted.

Please email all applications to: anila.paul@staff.uph.edu

dr Anila Paul MBBS, PGCertHsc, PGDipRehab

Vice Dean Student Affairs, Faculty of Medicine, UPH, LippoVillage, Tangerang
 (resume is included on the next page)

CURRICULUM VITAE

Student Number : 07120100042

Full name : Daniel Gunawan

Place, date of birth : Jakarta, 14 December 1992

Blood Type :A

Religion : Christian Protestant

Address : Batutulis 18, No 18 D, Jakarta Barat

Cell phone number : 08176815682

E-Mail : soccer_boyzzz@ymail.com

1. Educational Background :
a. SD : Kalam Kudus I , Lulus Tahun : 2004
b. SLTP : Kalam Kudus I , Lulus Tahun : 2007
c. SLTA : Kalam Kudus I , Lulus Tahun : 2010
2. Course & Education :
a. English Course EF General English
b. Guitar Piano Course
c.
3. Organization :
a. Ketua Osis (chief of student organization) SMA Kalam Kudus I
b.
c.
4. Work Experience : -
5. Academic :
a. 1st grade in Senior High school
b. 1st grade in EF Regional Spelling Bee Competition
c. Participant of EF National Spelling bee Competition