International Medical Experience Fund – College of Community Health Sciences

First Name *

Last Name *

CWID *

Email *

Description of the proposed travel and its purpose *

Schedule of travel *

Proposed budget *

Include specific details about how the costs were estimated.

Goals for the experience *

Outline of activities *

Describe the types of medical work that will be done, the facilities, and the types of patients.

Please indicate any other sources of funding that you have for this travel and the amount of funding (expected/proposed) from each source *

How does the travel fit with the CCHS Mission *

Letter of agreement from the proposed preceptor *

CV of the proposed preceptor

Not required if preceptor is a CCHS faculty member or well-known to CCHS

What other financial awards or scholarships have you received to apply toward the cost of your medical training? *

In regards to the above, what is the total amount of scholarship or award monies you have received or are going to receive? *

Scholarship Committee Review *

I understand that the CCHS Scholarship Committee (composed of faculty, staff, and community members) will review my application and discuss my academic and clinical performance as well as my financial situation.

Captcha *

For security verification, please enter any random two digit number. For example: 13