David M. Deci, MD Memorial
Student Scholarship Application
Students currently enrolled in medical schools based in the FMM states are eligible to apply for this scholarship. Applications are due at midnight June 30. Applicants are encouraged to give considerable thought to the essay questions and draft your answers in a separate document prior to beginning your application.
Applicants must have a presentation abstract accepted to present at the conference.
Name
First Name
*
Last Name
*
Medical School
*
Expected Graduation Year
*
Hometown (City, State)
*
How did you hear about Family Medicine Midwest?
Mailing Address
Street Address
*
Address Line 2
City
*
State
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Postal Code / Zip Code
*
E-Mail
*
Phone Number
*
What are you passionate about in Family Medicine?
*
What interests or activities do you have related to rural medicine, underserved communities and/or street medicine for those experiencing homelessness?
*
What is the Title of your presentation at the Family Medicine Midwest Conference? Please indicate if it's a poster or a session. The student awarded the David Deci Memorial Scholarship Award for Family Medicine Midwest is required to present at the Family Medicine Midwest Conference.
*
Are you a member of the AAFP?
*
Yes
No
AAFP Membership number
Have you attended this meeting in the past?
*
Yes
No
OPTIONAL: Briefly describe how you identify as someone underrepresented in medicine (500 character limit)
0/500
Submit
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