Travel Grant Application for Medical Students Fourth-year medical students may use the following application to apply for a travel grant for a GH elective. Due to the Covid epidemic, applicants must complete and submit the following document as part of the application: Covid Action Plan. Applications are processed on a rolling basis with a funding determination sent to the student within 3 weeks of submission. If you do not receive a response within 3 weeks of submission, email Ana Gregory.Today's Date:* Date Format: MM slash DD slash YYYY Section I: Student Information1. Student Name:* First Last 2. Class year of student:*Please enter a number from 2020 to 2030.3. Telephone of Student:*4. Email of Student:* Enter Email Confirm Email Section II: Host Information5. Primary Host Organization Name:*6. Host Contact Name:*7. Host Contact E-mail Address:* 8. Host Organization Website: 9. Host Address:* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanÅland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRéunionRomaniaRussiaRwandaSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUS Minor Outlying IslandsUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Section III: Details of Your ElectiveNOTE: The quality of the information that you provide below will assist the funding committee in determining the amount of funding you will receive. Provide as many details as possible in a well-written manner. 10. What is the main specialty of your GH elective (e.g., primary care, ob/gyn, etc.)?*11. Start Date of Elective:* Date Format: MM slash DD slash YYYY 12. End Date of Elective:* Date Format: MM slash DD slash YYYY 13. Total number of weeks abroad for your elective:*14. Destination Country:*15. Destination Cities and/or Towns:*16. Is there a State Dept. travel warning issued for your destination country?*NoYesNOTE: BUSM GH Program will not give academic credit for, pay for, supervise, direct, or otherwise support a medical student in a country where a U.S. State Department Travel Warning is in effect. See Travel Warning Policy.17. Is there a language requirement for the elective (besides English)?*NoYes18. If you answered 'Yes' for question 17, what languages are required and what is your skill level for these languages?19. Estimated Trip Costs:DIRECTONS: Enter an estimated dollar amount for each trip expense listed below; the form will total the expenses for you.> Airfare > Local Travel (bus, taxi, etc.) > Lodging > Food > Program Fee > Immunizations >> Total Estimated Expenses $0.00 20. For the expenses listed above, what is the source of your information (website, program contact, etc.)?*21. Have you applied for funding from other sources to support your elective?*NoYes22. If yes, what are these sources?23. What are the main components of your elective? (check all that apply)* clinical experience research language/cultural study community/public health project 24. Describe the clinical aspects of your elective including patient population, daily schedule, wards on which you will rotate, etc.*25. Describe the research aspects of your elective (if none, indicate that).*26. Describe the language study aspects of your elective, e.g., the amount of instruction you will receive, etc. (if no language component, indicate that).*27. Describe the community/public health aspects of your elective (if none, indicate that)*Section IV: Personal Reflection/How This Elective Fits into Your Career Plans28. How do your past experiences demonstrate your ability to make this a successful experience?*29. List the three main educational benefits that you expect to receive from your experience, including curriculum goals and/or post-graduate career plans. Benefit #1*Benefit #2*Benefit #3*Section V: Covid Action PlanSubmit the Covid Action Plan document. Due to the Covid epidemic, applicants must complete and submit the following document as part of the application: Covid Action Plan. 30. Submit Covid Action Plan document here:*31. Understand Your Responsibilities and Verify Your SubmissionAll students who undertake a 4th-year GH elective must complete the required list of responsibilities. Please review these responsibilities, then check the boxes below to submit your application. * I have read and understand the list of required responsibilities that I must complete before I undertake my elective (website listed above). * By submitting this form for consideration, I certify that, to the best of my knowledge, the information contained in the form is true and correct.