Dr. Rob Tingley Class of '95 Developing Countries Award & Joan Scarfone Memorial Award Application Form

Fields denoted by an asterisk (*) are required.

Name of Applicant: Name of Applicant: First Last
Email Address of Applicant
Program Location of Applicant
Graduating year of Applicant
What award are you applying for?

What award are you applying for? Dr. Rob Tingley Class of '95 Developing Countries Award Joan Scarfone Memorial Award Dr. P.H. Brooke International Travel Award in Medicine

Note: More than one award can be selected.
Destination country:
Maximum of 10 words allowed. Currently Entered: 0 words.
Estimated travel dates:

Note: travel must be completed within 6 months of this application.
Start Date Start Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Type of elective planned (please include specialty).
Maximum of 25 words allowed. Currently Entered: 0 words.
This award is intended to assist with travel and program expenses. Please provide the approximate cost of your elective, indicating travel, lodging and program expenses that you may incur.
Maximum of 500 words allowed. Currently Entered: 0 words.
In 1000 words or less, please describe the goals you wish to accomplish during this elective and how your experience in a low-resource/income country will contribute to your learning and career aspirations.
Maximum of 1000 words allowed. Currently Entered: 0 words.
Please attach your CV

Attach Files
Additional Comments
Maximum of 250 words allowed. Currently Entered: 0 words.