American Academy of Pediatrics




Funding & Awards  »   International Resident Elective Award
Also see:
International Elective Award Application
(Sponsored by the AAP Friends of Children Fund and the AAP Section on Medical Students, Residents and Fellowship Trainees)

APPLICATION FORM
DEADLINE: September 15 & March 15
GENERAL INFORMATION
Please make sure that your program director has also submitted his or her recommendation by the deadline.

Name

Please provide your age.

Please provide gender.

Female Male

What year will you finish your residency?

PGY

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. ie, name@domain.com)

Please check here if you hold Canadian citizenship.


ELECTIVE ABROAD
Please do not hit the enter button when completing the fields below

 

Host Country and City/Region

Host Preceptor

When are you leaving for your elective? (Type in this format: MM/DD/YYYY)

When will you return from your overseas elective? (Type in this format: MM/DD/YYYY)

Please provide a general description of your overseas elective:

What is your motivation for seeking such an elective, and how will it affect your career?

What will you do while you are there? Include information on the kind of facility and your objectives.

What kind of preparations have you made for your trip? (Immunizations, Visa(s), passes, housing arrangements while abroad).

If there will be a language barrier, how will you handle it?

You must make arrangements for medical care should you become ill. What preparations have you made?

Please briefly describe any previous international experience you have had?


CERTIFICATION

 

The elective award is payable to your institution for tax purposes. The check can be payable to you; however, you will be taxed on the award and receive a 1099 form from the AAP for the calendar year in which you received the award.
Please make the check payable to:


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

 

I, the applicant, understand that the decision to undertake study abroad is mine alone, and the American Academy of Pediatrics bears no responsibility for any health or safety risks presented by such study.
Provide applicant name as signature:

Date:

RECOMMENDATION INFORMATION

Please provide the information below for the person (program director, faculty mentor/advisor, or global health director) submitting the recommendation on your behalf. He or she will receive the link to the recommendation form once your application is submitted and processed.

Name and Address of Training Program

Name of Faculty Mentor/Advisor or Program Director

Faculty Mentor/Advisor or Program Director/ E-mail Address

Faculty Mentor/Advisor or Program Director Street

Faculty Mentor/Advisor or Program Director City

Faculty Mentor/Advisor or Program Director State

Faculty Mentor/Advisor or Program Director Zip

**Please review for accuracy **


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