WDS Medical Student Awareness Program Application | Grant Programs of the Women's Dermatologic Society

WOMEN'S DERMATOLOGIC SOCIETY
WDS Medical Student Awareness Grant Program Application

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Deadline For 2009 Award Is December 31, 2008

Application Date:

APPLICANT INFORMATION:

Name:
E-Mail:
Address:
City:
State:
Zip:
Telephone:
Fax:

Current Medical School:
City:
State:

PROSPECTIVE MEDICAL SCHOOL/INSTITUTE:

Name of School/Institute:
Address:
City:
State:
Zip:
Telephone:
Fax:
Proposed Partner: (if applicable)

Is proposed partner a WDS member?

Yes

PROSPECTIVE ELECTIVE INFORMATION:

Focus Is:
Beginning Date: (Must begin after March 1, 2008)
Ending Date:
Location:

BUDGET REQUEST:

You may eMail a separate budget worksheet if you wish, or use the space below. Keep in mind any additional expenses you may encounter, such as malpractice insurance.

• Transportation

If driving, what is the estimated mileage? Miles

If flying, what is the estimated airfare? $

• Lodging

• Food

• Other (describe below)

TOTAL REQUEST

STATEMENT OF PURPOSE TO INCLUDE THE FOLLOWING POINTS:

Describe your career goals.
Describe the goal(s) of the proposed elective and any specific project planned.
How do you envision this experience will impact your future career in medicine?

List Details Here

CURRICULUM VITAE:

LETTER OF RECOMMENDATION:

Letter of Recommendation from potential Medical School or Proposed Partner
(May be eMailed separately)

Letter of Recommendation from Dean of your current Medical School
(May be eMailed separately)

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This grant program generously sponsored by: Dermik Laboratories