Student Reimbursement Form for Travel Grant Student Reimbursement Form for Travel Grant Students may use this form to receive payment of their travel grant awarded for a global health fourth-year elective. This payment is a reimbursement that requires the following: Completion of a Post-Elective Report. Once the report is completed, notice is automatically sent to Ana Gregory. Submission of the form below and electronic copies of your trip receipts. Once the above items are submitted, you will receive a check to your mailing address in about three weeks. Questions? Contact Ana Gregory. Today's date* MM slash DD slash YYYY I. Student & Trip InformationStudent name* First Last This is the person receiving the reimbursement.Student e-mail address* Enter Email Confirm Email Student address (the check will be sent to this address)* Street Address City State / Province / Region ZIP / Postal Code On what date did you meet with Dr. Leanza for pre-departure training? This meeting is usually 1-2 months prior to the start date of your elective; it is a group meeting or an individual meeting with Dr. Leanza to discuss safety, etc. It is required of all students going abroad.* MM slash DD slash YYYY What were the dates of your trip?* In what country did you undertake your elective?* How much were you awarded for your travel grant?*II. Required DocumentsDid you complete the Post-Elective Report (see #1 above)* Yes No Hidden2. Upload your completion certificates from Parts 1, 2 & 3 of The Practitioner’s Guide to Global Health* Drop files here or Select files Max. file size: 100 MB. Upload Your Travel Receipts (in one PDF or Word document )* Drop files here or Select files Max. file size: 100 MB. Note on receipts: Submit your receipts in one PDF or Word document. The total amount of your receipts must be at least equal to the amount of your travel award. Additional receipts above this amount are not necessary to submit. The following receipts are acceptable: flight receipts, program fees, rental fees. Receipts must show proof of payment.NotesIf needed, please include any clarifying information regarding your reimbursement above.Hidden2. Upload your completion certificate for Course 3: “Reflection” of the Practitioner’s Guide to Global Health series.*Max. file size: 100 MB.