Identifying Information:

Proposed Mentorship Program/Activity:

Grants will be awarded based on the answers to these questions. Please be as thorough as possible.

Please identify which young member group this application/activity will be targeting. You may choose more than one.
Young Physicians
Residents
Medical Students

Please describe the mentoring program/activity.

How do you plan to sustain the program? What are your plans to longitudinally sustain the relationship between the mentee/mentor?

Date and Time of the event or time frame of the activity:

Research has shown that rewarding the mentor for their efforts has helped with the sustainability of the mentor/mentee relationship. How do you plan to reward or encourage the mentor?

Estimated number of participants (mentees) for your planned activity?
(Young Physicians, Residents, Medical Students):

What type of needs assessment will your chapter perform as part of this activity?

How will you evaluate the success of this activity, both long term and short term?

Has your chapter held any previous mentorship events or activities? If yes, please describe.

Budget for the Activity:

The amount of the grant award will be based on your proposed budget and the perceived need for funding.

Please indicate the amount of award requested for your activity (up to $1,000):

Please list a budget for the proposed activity. Include costs directly related to the event as well as the cost of advertising the event to your targeted young member group.

Please describe any other sources of funding available to the chapter for this activity, including chapter funds, if any.

Follow up:

A report on the success of the activity is required for any chapter awarded a grant. A follow up form will be sent if the grant is awarded and will also be available online. Please keep in mind that the follow-up form should include feedback from participants.

Who will be responsible for this report?

Confirmation: