*=Required Field
Please fill in application below

*Name:

*IAHPC Membership #

*Address 1:

Address 2:

*City:    *Country:

*Email:  

Phone Number:

*Specialty:

*Current position/title:

*Institution:

*Number of years since graduation:  

*Number of years working in palliative Care:

* Proportion of your current working time devoted to palliative care:
Full time:    Half time:    Equal or less than 30%:

*Name of Event / Meeting / Activity you are interested in participating in (include the name of the organization sponsoring it):

*City:    *Country:

*Proposed dates of travel
From: (mm/dd/yr)   To: (mm/dd/yr)

*Is this part of an ongoing educational program?  Yes No
If yes, have you received support from IAHPC in the past for this activity?
Yes No

*In the space below explain how do you expect this meeting/activity be helpful to you in the development of palliative care in your institution/community/country

*Describe the training and educational activities that will take place in
the event you want to participate in:

*Describe your educational needs based on your current activity
•If you plan to attend a meeting, please include a copy of the scientific program. In the space below, describe specific issues you hope to learn and how you expect them to meet your needs.
•If you plan to visit a teaching center, explain the activities (bedside teaching, clasroom teaching, patient rounds, discussion groups, etc) that will help you meet your needs. Describe specific issues you hope to learn (symptom control, research design, etc).

Amount of support requested (in US dollars):

Dollar Amounts Only No Cents
Round off to the next dollar amount.

*Air fare (economy class):US $

*Accomodation/Housing: US $

*Taxi/Train: US $

*Other Expenses:US $

Registration fees (if applicable)US $

*Total Amount requested:

*CLICK HERE  To Total Requested Amount  Grand Total US $

** If you have received or expect to receive funding from other sources, please specify donor and amount.

Donor(s):   Amount: US $

Comments:

If you are awarded this grant, you will need to sign an indemnity agreement form with IAHPC and write a report once your trip is completed.

If you agree to these conditions, please type your full name below, date and return this form with a copy of your CV to info@iahpc.com

I hereby sign in agreement to the above:

   *Name/Signature:         *Date (mm/dd/yr)

Thank you for completing this form!

PLEASE CHECK ALL REQUIRED FIELDS BEFORE SUBMITTING FORM!