2023-24 Student Stipend Application

2023-24 Student Funding Application
Section 1: Applicant Information
Name*

First NameLast Name
Personal Pronouns
Date of Birth*

MonthDayYear
Date
Race and Ethnicity (check all that apply)*

American Indian / Alaska NativeAsianBlack / African AmericanHispanic / LatinoMultiracialNative Hawaiian / Other Pacific IslanderWhiteOther
Gender Identity

ManWomanTransgenderGenderqueer/Non-binaryTwo-SpiritAgenderOther
Student ID Number*
University of Washington Employee ID Number (if applicable, to expedite payment)
Phone Number*

Area CodePhone Number
University Email Address*
Personal Email Address*
example@example.com
University Attending*
Academic Level*

Undergraduate JuniorUndergraduate SeniorMasterDoctoral
Enrollment Status*

Full-timePart-time
Degree*

BABSMPHMSMAMSWPhDOther
Primary Discipline*

PsychologyPublic HealthSocial WorkSociology
Name of Academic Program*
Example: Master of Public Health
Personal Statement

In no more than 300 words, briefly describe how undertaking this project supports your academic goals and will contribute to your development as a public health practitioner. Note how your personal background has impacted your ability to obtain the knowledge or skills necessary to participate in your current academic program.
Personal Statement*
Letter of Support

Undergraduate applicants must include a letter of support from a faculty adviser or other faculty member they are working with on the project.
Upload Letter of Support
Section 2: Project Information
I am applying for a:*

Student Field Placement stipendFaculty-Student Collaborative Project stipend
Project Faculty Adviser*

First NameLast Name
Project Faculty Adviser Email *
example@example.com
Project Title*
Project Estimated Start Date*
Project Estimated End Date*
Student projects must be completed by the end of spring term 2024
My project is located in:*

AlaskaIdahoOregonWashington
My project will occur in or with a: (check all that apply):*

Primary care settingMedically underserved areaMedically underserved populationRural settingNone of the above
Project Abstract

Copy the abstract from YOUR project plan that describes the public health problem your project addresses, the work you intend to do, and the anticipated deliverables.
Project Abstract*
Personal Learning Objectives

Please identify two or three learning objectives you hope to achieve as a result of this placement/project. Below are some guidelines for developing a learning objective.
- Learning objectives are measurable and should describe the skills or competencies you will gain by conducting a field placement or collaborative project.
- Learning objectives should be short and focus on a single outcome. (e.g., At the end of this project, I will be able to conduct a literature review, analyze quantitative data with statistical software, and develop a comprehensive evaluation plan.)
Learning objectives:*
This project is considered a:*

PracticumCapstone or thesisDissertationNone of the above
Number of credits you are receiving for your project. Answer '0' if not applicable:*
Have you received funding for this project from any other source?*

YesNo
Section 3: Partner Organization Information
Partner Organization Name*
Are you employed at this organization?*

YesNo
Are you receiving funding or other compensation from this organization for your proposed project?*

YesNo
Type of Organization:*

Community-based or non-profit organizationFederal agencyHospital, medical center, clinic, or other health care delivery centerLocal or state health departmentTribe or tribal-serving organizationOther
Organization Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Site Supervisor*

First NameLast Name
Site Supervisor's Title*
Site Supervisor's Email Address*
Section 4: Project Plan

Upload YOUR detailed project plan including methods and a timeline of tasks and deliverables. (You may submit a formal proposal YOU have previously prepared for an academic program or a funder, if appropriate.)
Upload project plan *
Section 5: Curriculum Vitae/Résumé

Upload a copy of your CV or résumé. It should include your educational and employment history, any professional memberships and activities, and any publications, presentations, and projects completed.
Upload CV or résumé*
Section 6: Additional Requirements

Eligibility

I understand that students are only eligible to receive this funding award one time and I confirm that I have not previously received it.

Citizenship Status

Each student receiving stipend must be a U.S. citizen, a non-citizen U.S. national, or a foreign national with a visa permitting permanent residence in the United States. Individuals on temporary or student visas are not eligible.

Photography

The Northwest Center for Public Health Practice (NWCPHP) may take photos and videos as part of your field placement or collaborative project for use in its educational and promotional materials. You grant NWCPHP full rights without compensation to use any photos, videos, or recordings containing your likeness taken during the routine course of the event, by NWCPHP or its official representatives, to be used in future educational or promotional endeavors of NWCPHP, the School of Public Health, and the University of Washington, without any further notice. This permission may be revoked in writing to NWCPHP.
Acceptance of terms*

I have read and agree to all of the requirements described above.
How did you learn about this opportunity? *

Academic adviserConference, meeting, or other eventE-mail announcementFormer stipend recipientManager or supervisorNWCPHP staff or facultyNWCPHP websitePostcard or flyerSocial media (Facebook, LinkedIn)StudentOther
The Northwest Center for Public Health Practice at the University of Washington School of Public Health is one of ten regional Public Health Training Centers funded by the Health Resources and Services Administration.
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2023-24 Student Funding Application