Carey Phillips Student Travel Fellowships Application Subscribe The Carey Phillips Student Travel Fellowship Application Please provide all supporting documentation with this application as one submission. Be sure to read the Guidelines before starting the application process so that you have all necessary materials ready to attach. NamePrefix- Select -Dr.Mr.Mrs.Ms.First NameLast NameSuffixLocal AddressAddress Line 1Address Line 2CityStateZip CodeContact InformationPhone/MobileEmailDate of BirthMarital StatusHometown / StateUndergraduate CollegeClass YearHospital Service Next 60 DaysTravel InformationDeparture DateReturn DateDuration of StayTravel Destination (Institution or Training Site):Purpose of Visit (Research, Study, etc.)Will your visit take place during elective period or other?How do you expect the training program to benefit you in your future medical career?Anticipated SpecialtyType of PracticeOther CommentsFinancials Housing and meals are not reimbursed, but are requested to determine the total cost of the visit.Housing Expenses $Meals Expenses $Transportation Expenses $Are other funds available to you to help defray the total cost of your visit? Yes NoFaculty Sponsor Contact InformationFaculty Sponsor's NameFaculty Sponsor's Campus Phone NumberFaculty Sponsor's Campus AddressUpload Your Three Required Supporting Documents Here PDF documents are preferred. Other allowed formats are: jpg, png, doc, docx, rtf, txt, xls, xlsx, ppt, pptx. Max File size is 3 mb. Letter from the faculty sponsor should include the nature and duration of training. Notice of Good Standing from Heersink School of Medicine. Letter of acceptance/invitation from responsible staff member at study site Browse Files - Drag and drop files here Signature Required The conditions of the student travel fellowship have been explained to me. I understand that I must make my own travel arrangements and that I will travel at my own risk.Signature Sign Here Submit Form Who may become a member? Anyone (medical or non-medical) who contributes $200.00 per year to the Club.
