Family Medicine Midwest 2018 Student Scholarship Application

All medical students who wish to apply for this scholarship need to complete this form. Students currently enrolled in medical schools based in the FMM states are eligible for scholarships. Applications are due at midnight September 2. Applicants are encouraged to give considerable thought to the essay questions and draft your answers in a separate document prior to beginning your application.
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*
Postal Code / Zip Code*
E-Mail*
Phone Number*
What are you passionate about as it relates to Family Medicine? *
What interests or activities do you have related to rural medicine and/or street medicine for those experiencing homelessness?*
What is the focus of the poster that you will present at the Family Medicine Midwest Conference? (The student awarded the David Deci Memorial Scholarship Award for Family Medicine Midwest is required to present a poster at the Family Medicine Midwest Conference.)*
Are you a member of the AAFP?*

YesNo
AAFP Membership number
Have you attended this meeting in the past?*

YesNo
OPTIONAL: Briefly describe how you identify as someone underrepresented in medicine (500 character limit)

0/500
Should be Empty: