2024 Scholars Program Application
We encourage applications from women, BIPOC, LGBTQIA+ persons, persons who are differently abled, persons from disadvantaged backgrounds, protected veterans, and anyone who identifies as an underrepresented minority. Due October 1, 2023.
Name:
*
First Name
Last Name
Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number:
*
Please enter a valid phone number.
City & State:
*
Permanent Email:
*
example@example.com
Are you of Hispanic, Latino, or Spanish origin?
No, not Hispanic, Latino, or Spanish Origin.
Yes, Mexican, Mexican American, Chicano.
Yes, Puerto Rican.
Yes, Cuban, Cuban American.
Yes, another Hispanic, Latino or Spanish origin.
Select the racial category/categories you most closely identify yourself with. (Check all that apply)
American Indian or Alaska Native
Asian
African-American
Native Hawaiian or other Pacific Islanders
Caucasian
Other
What is your gender? (Check all that apply)
Woman
Man
Transgender
Non-binary
Intersex
Prefer Not to Answer
Other
Which of the following best represents how you think of yourself? (Check all that apply)
Heterosexual/Straight
Gay
Lesbian
Bisexual
Pansexual
Asexual
Queer
Prefer to Not Answer
Other
Currently enrolled in:
*
Medical School
Psychiatry Residency
MS 1
MS 2
MS 3
MS 4
PGY 1
PGY 2
PGY 3
Name of Your Medical School or Psychiatry Residency Program
*
File Upload: CV
*
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File Upload: Letter of Intent and Interest
*
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File Upload: Letter of Recommendation
*
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File Upload: Bio Sketch (200 words describing your training and accomplishments to be shared with your scholarship donor)
*
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of
For residents only:
I have read and understand the requirements for Honors Scholars, which extendbeyond the attendance requirements for the Annual Meeting Scholars Program. Iagree to participate fully if selected for this program.
I am not fast-tracking into a child psychiatry fellowship.
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