WDS Medical Student Awareness Program Application

WDS Medical Student Awareness Program Application

WOMEN'S DERMATOLOGIC SOCIETY
WDS Medical Student Awareness Program Application
Application Deadline: December 31, 2009

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Application Date:

APPLICANT INFORMATION:

Name:
E-Mail:
Address:
City:
State:
Zip:
Telephone:
Fax:

Current Medical School:
City:
State:

PROSPECTIVE MEDICAL SCHOOL/INSTITUTE:

Name of School/Institute:
Address:
City:
State:
Zip:
Telephone:
Fax:
Proposed Partner: (if applicable)

Is proposed partner a WDS member?

Yes

PROSPECTIVE ELECTIVE INFORMATION:

Focus Is:
Beginning Date: (Must begin after April 1, 2009)
Ending Date:
Location:

BUDGET REQUEST:

(You may eMail a separate budget worksheet if you wish, or use the space below)

• Transportation

If driving, what is the estimated mileage? (please be specific)

If flying, what is the estimated airfare? $ (please be specific)

• Lodging

• Food

• Other (describe below)

TOTAL REQUEST

STATEMENT OF PURPOSE TO INCLUDE THE FOLLOWING POINTS:

Describe your career goals.
Describe the goal(s) of the proposed elective and any specific project planned.
How do you envision this experience will impact your future career in medicine?

List Details Here

CURRICULUM VITAE:

LETTER OF RECOMMENDATION:

Letter of Recommendation from potential Medical School or Proposed Partner
(May be eMailed separately)

Letter of Recommendation from Dean of your current Medical School
(May be eMailed separately)

Application Deadline: December 31, 2009

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