Medical Humanities Funding Request
Name
*
First Name
Last Name
Email
*
example@example.com
Indicate your status for requesting funding. Select one from below:
*
Please Select
I am a declared Medical Humanities minor.
I am a current student in a Medical Humanities course requesting research funds.
I am an officer in the Medical Humanities club or another club related to Medical Humanities
Indicate which club you are affiliated with:
Describe the need for anticipated use of requested funds (up to 250 words):
*
Indicate your budget below, including detailed use of funds requested from the Medical Humanities Program and plans for covering remaining expenses (if any).
*
Indicate the date of your event (if applicable) or anticipated date needed for funds (if time-sensitive)
-
Month
-
Day
Year
Date
Mention other secured funds and sources:
Use the space below to share any additional information you feel is important for us to consider:
Optional. You may include a draft of your research project, link to a conference description (2nd box below), invoice, or any other relevant material (Please combine into a single PDF)
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