Application for Scholarship From SGHC
This application is to support trainees in AMWA’s Sex and Gender Health Collaborative in their opportunities to present and disseminate their work as part of the committee. We ask all trainees to request their institution for support as well. All submission and printing costs will be covered. Other expenses will be covered up to $100. We understand this amount does not cover all incurred costs and are working to expand our scholarship fund.
Name
*
First Name
Last Name
Email
*
example@example.com
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
Institution:
*
Training Status:
*
Pre-medical student
Medical student
Resident
Other
Are you an AMWA Member
*
Yes
No
Name of Event:
*
Location of Event:
*
Distance From Your Home (in miles):
*
Institution Sponsoring/Hosting the Event:
*
We ask all trainees to request support from their institution in addition to the SGHC fund. Did your institution offer any support?
*
Yes
No
Amount Recieved:
*
What activity/work did you create and distribute for SGHC? Please select all that apply.
*
Submitted an abstract/publication
Created a Fact Sheet
Traveled to present a poster
Traveled to present a Fact Sheet/Poster on a specific topic
Worked at an exhibit table to promote SGHC
Worked at an SGHC fundraiser
Other
Please list any costs you incurred
Submission Fee:
*
Registration Fee:
*
Printing/Material Costs:
*
Transportation (air, train, uber/cab):
*
Lodging:
*
Please Upload All Receipts for the above costs.
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