MEDICAL RELIEF PROVIDER TRAINING APPLICATION FORM

(MARCH INTAKE YEAR 2019)

This form should be completed in BLOCK-LETTERS and returned
together with required attachments to The Director, Human
Health And Nutrition Initiatve Malawi, P.O Box 33421, Lilongwe.
Or send the form to medicalhealth2019@gmail.com
DEADLINE FOR RECEIVING APPLICATION FORM IS 8TH FEBRUARY 2019

A. PERSONAL DETAILS
Surname_____________________________ First Name___________________
Sex : { } Male Female { } Date of birth_____________________
Nationality_________________________________________
Contact postal
address__________________________________________________________
________________________________________________________________
________________________________________________________________
______________________________________________________________

Phone number__________________________________________
Email__________________________________________(optional)
Next of kin Contact phone
number________________________________________________
 B. ACADEMIC DETAILS
MSCE { } O-Level { } A-Level { } Onther_____________________

SECONDARY SCHOOL
NAME_______________________________________________________
SUBJECTS GRADE YEAR
1
2
3
4
5
6
7
8
9
10
Make sure that the subjects you write on this above table corresond to those on your MSCE certificate/
notification of resurts

C. RESIDENTIAL DETAILS
Name your residential district______________________________
Name your Home District______________________________________
Name your Home village_____________________________________
Name your Traditional Autholity (T/A)_______________________________
Name your nearest health faclility/ hospital___________________________

Tell us why do you want to join health

professional______________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________
MEDICAL RELIEF PROVIDER ASSISTANT TRAINING AGREEMENT

The Human Health And Nutrition Initiative Malawi is committed to the

development and training of all its Student. To this end the oganization will
support through negotiation, funding and or time for training particulary those
studying Certificate in Medical Relief Provider, However the Human Health And
Nutrition Initiative Malawi expects that Medical relief provider Students will;
1. Complete designated training for the whole 5 months
2. Use the training to benefit the people of Malawi mainly in health sector
3. Pay back 100% of the total cost of the course if students leaves the
training within 5 months from commencement of the training
4. Be willing to pay MK30,000. (Thirty thousand kwacha) for the whole 5
months as partal contribution fee within 3 months of training
5. The Ministry put this new post of Medical Relief provider Assistant at
grade M , so applicant has to agree to be on that grade on salary scale
segment after finishing the training

Duties after finishing training

i. Providing basic medical treatment to people in rural areas
ii. Provide medical checkup to people in their areas by visiting door
to door hence the theme ``Dokotala wa khomo ndi Khomo``
iii. Prescribing required drugs to patients in their homes
iv. Attending meetings and conferences instructed by in charges of
health centres
v. Provide health talk to communities on regular basis
vi. Atending medical emergencies such as Road traffic accidents ,
floods , assault etc under supervision of Clinical officer or Medical
officer.

I agree to be trained as Medical relief provider under Ministry of Health

through Human Health And Nutrition Initiative Malawi. I will follow and
agree to above statements
Name____________________________________signature_______________
 D. APPLICATION FEE
Interested Applicants are required to deposit APPLICATION FEE of K6000 (Six
thousand kwacha only) to the following financial institution
ECOBANK
Account Name : Human Health Nutritional Initiative Training Program
Account number: 14700054216 , Lilongwe Branch
Remember to attach your bank deposit slip to this form
The application fee can also be send to our strictly MPAMBA ACCOUNT
NUMBER BELOW and write your transaction details in the table below

AGENT CODE
REFERENCE NUMBER
TRASACTION DATE

Those using their own Mpamba account number use table below
PHONE NUMBER USED
REFERENCE NUMBER
TRANSACTION DATE

I hereby certify that informattion given above is true to the best of my knowledge
Signature__________________________________Date_______________________