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MEDICAL REHABILITATION COUNCIL OF
ZIMBABWE
14 Betram Road P.O.Box A667
Milton Park AVONDALE
HARARE HARARE
ZIMBABWE
TELEPHONE: (263) 04 778244
EMAIL: mrczimbabwe@gmail.com
APPLICATION FORM FOR ZIMBABWE TRAINED APPLICANTS
MANDATORY DOCUMENTS TO BE SUBMITTED WITH THIS FORM
CHECKLIST (Please tick)
Applicant Office use
1. Certified copies of Degrees , Diplomas, Certificates X
2. Certified copy of Identity Card X
3. Syllabus of training X
4. Two passport-size photographs X
NOTE:
(i) The Council is empowered to require an applicant to comply with specific requirements e.g
employment under supervision, as a condition of registration.
(ii) It is an offence to practise any medical profession in Zimbabwe without registration or without
a current practicing Certificate according to the Health Professions Act (Chapter 27:19).
(iii) Incomplete applications may be subject to delay in processing.
Profession: Sport Scientist
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1. PERSONAL DATA
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SURNAME Wushe
FIRST NAME (s) Sandra Ntombizanele
PREVIOUS NAMES Dube
(Where applicable)
DATE OF BIRTH 12-Oct-1986
I.D NUMBER 08-801966D21
TITLE Mrs
SEX Female
PLACE OF BIRTH: TOWN Bulawayo
COUNTRY Zimbabwe
NATIONALITY Zimbabwe
PASSPORT: Yes/No. If yes please give number
and expiry date
CULTURAL COMPETENCE I am a local and thus culturally competent
RELIGION Christian
WORK PERMIT: Yes/No. If yes please give details --Not Applicable--
PERMANENT HOME ADDRESS 8152 Nkulumane, Bulawayo
CONTACT ADDRESS 8152 Nkulumane, Bulawayo
PHONE NUMBER 071 176 6915
EMAIL ADDRESS sandra.n.dube@gmail.com
2. PROFESSIONAL QUALIFICATIONS
QUALIFICATIONS NAME OF TRAINING DURATION AWARDED DATE
((Dip/Cert/Degree/MSc/Clinical INSTITUTE BY AWARDED
Doctorate/PHD) FROM TO
BSc. (Hons) Sport Science National University 2007 - 2010 NUST 22 Oct. 2010
of Science &
Technology
ADDITIONAL INFORMATION
Profession: Sport Scientist
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3. DETAILS OF INTERNSHIP (where applicable)
NAME AND PLACE FROM TO DESCIPLINE
--Not Applicable--
4. PROFESSIONAL REGISTRATION
REGISTRATION COUNTRY DATE OF ISSUE EXPIRY DATE
AUTHORITY AND
CURRENT LICENSE
NUMBER
--None--
5. MEMBERSHIP WITH PROFESSIONAL ASSOCIATION:
NAME OF COUNTRY MEMBERSHIP MEMEBRSHIP EXPIRY
PROFESSIONAL NUMBER (if applicable) DATE (if applicable)
ASSOCIATION
--None--
Profession: Sport Scientist
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6. RELEVANT WORK HISTORY (where applicable)
Please list all work history starting with the most current position at the top. You may print and attach
more pages if necessary.
FROM TO: EMPLOYER’S NAME AND JOB TITLE BRIEF JOB DESCRIPTION
(DD/MM/YY) (DD/MM/YY) ADDRESS
Mar. 2015 Feb. 2020 North West University Lecturer -Diploma in Sport Science
Mmabatho -Bachelor in Human
Mafikeng Movement Science
-Developed & delivered
academic programs
PhASRec Research -Data collection & statistical
Apr. 2012 Feb. 2015 North West University Assistant analysis
Potchefstroom -Monitoring & evaluation of
programs/intervention
Sep. 2010 Mar. 2012 Dominican Convent High Sports Teacher -Taught PE
Bulawayo -Sports Coaching
-Physical activity programs
7. CPD (List your most immediate CPD participation in the last 5 years in the following table)
Date Event and duration Presenter Method of evaluation
Oct. 2024 Weight Management: Beyond Emory University Summative Assessment
Balancing Calories
Oct. 2024 Cert. Health Behaviour Change Yale University Summative Assessment
Aug. 2024 Program Design & Evaluation for Johns Hopkins Summative Assessment
Health Systems Strengthening University
Oct. 2024 Diagnosing Health Behaviours for Johns Hopkins Summative Assessment
Global Health University
May 2023 Exercise is Medicine & Type I and Dr. Torres Summative assessment
II Diabetes
May 2023 Exercise is Medicine & Dr. Torres Summative Assessment
Hypertension
Mar 2023 Exercise Prescription for Health Dr. Torres Summative Assessment
May 2023 Exercise & Pregnancy Dr. Torres Summative Assessment
Feb 2023 Physical Activity Assessment Dr. Torress Summative Assessment
Note: Attach evidence (e.g. certificates)
If no CPD activity give reasons:
…………………………………………………………………………………………………………………………
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…………………………………………………………………………………………………………………………
…………………………………………………………………………………………………………………………
8. State any clinical area(s) of interest/specialty (if applicable):
Research, Physical activity, Non-Communicable Disease (such as Diabetes, Hypertension)
E.g., Neurology, Cardiovascular, Research and Administration, etc.
9. Statutory Declaration
(This must be made before someone entitled to take statutory declaration e.g. Solicitor, Commissioner of
Oaths, who must provide their full name, physical address and contact telephone and email):
I hereby certify that the information I have given above is correct. With this application, I confirm
that I am fit and qualified to practice as a.........................………………………………………………I
understand that a misrepresentation of information will result in my application being disqualified.
Name of applicant: .............................................................................................
Signature of applicant: .................................................................................
Declared at (location).......................................................................
This: ....................................... day of: ........................................... year..............................................
Before me (official authorised to take a statutory declaration):
Full name of official: ..........................................................................................
Signature of official: ..............................................................
(Designation, full address, phone number and official seal):
DATE: ............................................................................................. SIGNATURE............................
Profession: Sport Scientist
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FOR OFFICIAL USE ONLY
APPROVED
YES NO.
IF YES:
DATE OF REGISTRATION.............................................................................................................
REGISTRATION NUMBER..............................................................................................................
CONDITIONS...................................................................................................................................
IF NO:
REASON..........................................................................................................................................
DATE...................................................................................SIGNATURE.........................................
NOTE:
10. PAYMENT
A NON-REFUNDABLE FEE OF:
APPLICATION FEE USD 100.00
CERTIFICATE FEE USD 27.00
TRAINEE FEE USD 33.00 (3YRS)
IS NEEDED TO PROCESS THIS APPLICATION.
MEDICAL REHABILITATION COUNCIL’S BANK ACCOUNTS
Account Name Account Type Account Branch Account Number Branch
Currency Code Name
MEDICAL REHABILITATION Banc ABC NOSTRO USD 108 54187546633010 MSASA
PRACTITIONERS COUNCIL
MEDICAL REHABILITATION Banc ABC CURRENT ZWL 108 54187545502017 MSASA
PRACTITIONERS COUNCIL ACCOUNT
MEDICAL REHABILITATION CABS NOSTRO USD 1125289465 FOURTH
PRACTITIONERS COUNCIL STREET
MEDICAL REHABILITATION CABS SAVINGS ACCOUNT ZWL 1004389094 FOURTH
PRACTITIONERS COUNCIL STREET
MEDICAL REHABILITATION FIRST CAPITAL SAVINGS ZWL 2144 1037449 PEARL
PRACTITIONERS COUNCIL ACCOUNT HOUSE
