Conference Funding for Trainees

Fields denoted by an asterisk (*) are required.

Amount Requested

Please enter numbers only, no decimal, or commas.
Name Name First Last
Email
Enrollment

Enrollment Resident Medical Student
Which program are you enrolled in?
Contact Information
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Telephone Telephone - ### - ### ####
Cell phone Cell phone - ### - ### ####
Event Information
Event:
Sanctioned or sponsored by:
Location of Event:
Weblink for Event:
Proposed dates of attendance:
Start Date Start Date / MM / DD YYYY
End Date End Date / MM / DD YYYY
Has permission been granted from UGE or PGE Program Director to attend the event?

Has permission been granted from UGE or PGE Program Director to attend the event? Yes No
What is your objective in attending this event?
Describe your planned participation.
What faculty support have you received?
Is your interest in attendance due in any part to an elective or core rotation you have undertaken in a rural regional community?

Is your interest in attendance due in any part to an elective or core rotation you have undertaken in a rural regional community? Yes No
Have you attended this conference previously?

Have you attended this conference previously? Yes No
What are your future practice plans?
In order to process this application notification of acceptance must be emailed to:
distributed.education@schulich.uwo.ca
I Agree to the above terms

I Agree to the above terms Yes No