Travel Grant Application for Medical Students

Today's Date:*

Section I: Student Information

1. Student Name:*

First Last

2. Class year of student:*

Please enter a number from 2020 to 2030.

3. Student Phone:*

4. Student E-mail*

Enter Email Confirm Email

Section II: Host Information

5. 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 Country

Section III: Details of Your Elective

NOTE: 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:*

12. End Date of Elective:*

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?*

No
Yes

NOTE: 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)?*

No
Yes

18. If you answered 'Yes' for question 17, what languages are required and what is your skill level for these languages?

Section IV: Estimated Trip Costs

19. What are your estimated trip costs?

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?*

No
Yes

22. If yes, what are these sources?

Section V: Describe the Different Aspects of Your Elective

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 VI: Personal Reflection/How This Elective Fits into Your Career Plans

28. 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 VII: If Your Elective Program is Cancelled

30. If your elective program is abruptly ended due to disaster-level conditions (civil unrest, natural disaster) or Covid, what are your plans for accommodations and return flight to US?*

31. Do you have housing in the U.S. if your elective program is cancelled?*

Yes
No

Section VIII: Understand Your Responsiblities & Verify Your Submission

All 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).*

Check here to confirm the above.

By submitting this form for consideration, I certify that, to the best of my knowledge, the information contained in the from is true and correct.*

I certify the above.

Hidden

I have read and understand the list of required responsibilities that I must complete before I undertake my elective (website listed above).

Hidden

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.

Hidden

30. Submit Covid Action Plan document here:

Max. file size: 100 MB.