American Academy of Pediatrics




Funding & Awards  »   Anne E. Dyson Child Advocacy Award
Also see:
Anne E. Dyson Child Advocacy Award

(Supported by an educational grant from the Dyson Foundation)

 

One resident should be identified as the project leader for this award and should be a member of the AAP. That person should complete all questions. (Residents may work as a team on the application but identifying a single project leader is necessary from a logistical standpoint.) Applications will be judged on the basis of resident or medical student involvement, project sustainability, originality, and overall impact on child health.

APPLICATION FORM
DEADLINE: July 18, 2014

GENERAL INFORMATION

 

Project Leader's Name

MAILING ADDRESS:
Street
City
State
Zip
Permanent Address,
if different than above.
(Street City State Zip)

Home Telephone

Office Telephone

Primary E-mail Address
(Please use valid e-mail format. i.e., name@domain.com)

Co-Leader's Name

Co-Leader's MAILING ADDRESS:
Co-Leader's Street
Co-Leader's City
Co-Leader's State
Co-Leader's Zip
Co-Leader's Permanent Address,
if different than above.
(Street City State Zip)

Co-Leader's Home Telephone

Co-Leader's Office Telephone

Co-Leader's Primary E-mail Address
(Please use valid e-mail format. ie, name@domain.com)


ADVOCACY PROJECT

 

Project Title

Please provide a general description of your child advocacy project, including the need being addressed by the project:

Please provide a short history of the project? How long has the project been in existence?

Did you create this program?

YES NO

Is this project considered as your community pediatrics rotation, as part of your residency training?

YES NO

Describe roles of residents in the project.

Describe roles of faculty in the project.

Are you receiving funding from other sources for this project?

YES NO

Please elaborate on funding from other sources.

What plans (if any) have been made for the continuation of the program after you graduate?


CERTIFICATION

 

IMPORTANT: Please send a letter via e-mail from your faculty sponsor or residency director in support of this application to: Kimberley VandenBrook by the July 18, 2014 deadline.


I, (Project Leader) hereby certify that all the questions on the application form have been answered completely and accurately to the best of my knowledge.


If I receive the award, the $300 honoraria check will be used for the project named above, and the check should be made out to: (Checks can be made out to individuals or institutions. Please note that you will receive a tax statement from the AAP if you receive $600 or more from the AAP in the calendar year.)

Name of Training Program

Name of Program Director
Program Director E-mail Address
Program Director Street
Program Director City
Program Director State
Program Director Zip
Name of Department Chairperson:



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