IUSM_Bloomington Summer Activities Funding Application

Returning?

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Purpose:

Purpose: The purpose of the grant is to support and increase the number of IUSM Bloomington medical students participating in summer research and organized summer medical experiences. A review committee will evaluate the applications and the availability of the grant is on a competitive basis.

Qualifications:

Must be enrolled as IUSM Bloomington first year medical student in good standing.
Must show proof of acceptance into the program.

Restrictions:

Award can only be applied to A. Registration Fee; B. Transportation; and C. Hotel Accommodations, if applicable.
If you have been awarded the grant, you are asked to submit proof of attendance in order to receive the funds in your Bursar account. Upon your return, please submit a 1/2-page synopsis of experience and receipts (registration, airfare, and/or lodging accommodations).

Deadlines:

January 15, 2020

Today's Date

M-D-Y

10-Digit University ID Number

First Name

* must provide value

Middle Name

Last Name

* must provide value

Street Address

City

State

Zip Code

Street Address

City

State

Zip Code

Contact Telephone Number (Area Code-###-####)

E-mail Address

* must provide value

What is the name of program you plan to participate?

Please provide the program's website URL.

Program Start Date

M-D-Y

Program End Date

Is there a stipend for the program?

Yes

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What is the stipend amount?

What program due dates and deadlines exist, if any?

Please provide a brief description of the program. (150 words maximum)

* must provide value

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How would this program advance your professional development? What do you expect to gain or accomplish from completing this program? Maximum 200 words.

* must provide value

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Itemized list of expenses with estimate costs.

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Total Estimated Cost

Total Amount Requested

Budget Justification (please provide information on the expenses listed above).

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Upload PDFs and/or images of the registration cost, proposed housing information and proposed flight.

* must provide value

Upload file

What other sources of funding might you or will you receive for supporting your program request?

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To what other programs have you applied?

What are other concerns or considerations, if any?

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