IAHPC Travelling Fellowship in Palliative Care
Host Application

Please enter details of host organization below
then click the "Submit" button

This form is to be completed by the unit / service which has invited the applicant for the IAHPC to visit and help them. Please describe in detail why the assistance of an IAHPC Travelling Fellow is sought and your objectives and expectations for the visit.

Applying Host may complete the information on-line using this version.
If Host wishes to mail or fax click here

Applicant and host BOTH must have paid appropriate IAHPC membership fees. Applications for membership can be completed on-line by clicking here

PLEASE ENTER THE DETAILS OF NEEDS AND EXPECTATIONS OF HOST UNIT / SERVICE (not the applicant)

*=Required Field

*Why is a Travelling Fellow is being invited to visit your unit / service?

*Outline the specific expectations which you have for such a visit

*Describe in detail the proposed schedule and plan for a Travelling Fellow’s stay with your unit / service.

*Provide detailed costs of accommodation and travel costs within your country

*Name of host organization

*Name of proposed Traveling Fellow

Title of Traveling Fellow

*Address

Address2

*City

*State/Province

Zip/Postal Code

*Country:

*Email:

*Verify Email:

Phone: (Enter with country and city-area code)

Fax: (Enter with country and city-area code)

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