Please fill out the following information and click 'Submit'.

IAHPC Traveling Scholarship Program

This is an ongoing program, so there are no deadlines for applications unless stated.
However, we need enough time to review your application and prepare the
required paperwork in case it is awarded. Applications should be
received at least 3 months in advance of your expected travel and meeting.

*=Required Field

Applicant Information

*Name of Applicant
*IAHPC Membership Number
*Address
Address2
*City
State/Province
Zip/Postal Code
*Country
*Applicant Email
*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
75% Time
50% Time
Equal or less than 30%
Activities
*Name of Event / Meeting / Activity you wish to attend or participate
*Event City
*Event Country
*Event dates from: *Dates To:
Indicate if you will be presenting a poster or oral presentation
Yes No
If Yes, title
In the spaces below please provide the information concerning the host/sponsoring organization/institution
*Name of sponsoring/host organization/institution
Host Contact Person
Host Phone
Host Fax
Host Email
*List Objectives and outcomes you want to achieve by participating in this activity
2000 characters remaining.

Expenses

*Air Fare (economy class) US $
Accommodation/Housing US $
Taxi/Train US $
Other Expenses US $
*Total Amount Requested US $
** If you have received or expect to receive funding from other sources, please specify donor and amount.
Donor(s)
Amount US $
Comments
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