Request for Funding from the NCAFP Foundation: AAFP National Conference for FM Residents & Medical Students
July 25 - 27, 2019 ~ Kansas City, MO

You must be an AAFP/NCAFP member in order to be eligible for funding. If you are not, please join at www.aafp.org/join

Deadline to Request NCAFP Support: June 15th, 11:59 pm. If you cannot meet this deadline you may still apply for funding in case any remains.

AAFP Early Bird registration rate ends in early July (please check their site for specific day), once that date passes, student registration rates will increase by $50.00.

Notifications of funding will be provided by 6/24/19. Funding is intended to supplement and help offset food/registration costs, it will not cover all conference expenses. You are encouraged to talk with your medical school regarding other possible funding sources. Amount of support ranges from $200.00 to $350.00, depending on # of requests received. If there are more requests than funding available a lottery drawing will be implemented.

For questions please contact Tracie Hazelett at NCAFP offices: thazelett@ncafp.com or 919-980-5357 or via Text messaging at 919-210-7409.

Email address *
Last Name *
Your answer
First Name *
Your answer
Alternate Email
Your answer
Mobile Phone# *
Your answer
Medical School *
Expected Graduation Year *
How did you hear about this funding? *
Required
Current Complete Mailing Address *
This will be used to mail award checks
Your answer
Are you a Member of: *
Required
Did you apply for an AAFP Travel Scholarship to attend? *
If Yes, which one? If No, why Not? *
Options were: Early Career Student, Student Primary Care Champion, FMIG Leader or the Family Medicine Leads - Emerging Leader Institute.
Your answer
Intended date of arrival in KC *
The conference begins Thurs. 7/25 at 7AM. For complete conference & schedule details please visit: www.aafp.org/events/national-conference.html
Intended date of Departure from KC *
Final National Keynote Speaker ends at 2:00 PM - For complete conference & schedule details please visit: www.aafp.org/events/national-conference.html
Have you purchased Airfare? *
Have you made hotel reservations? *
Block rates end July 6 but be aware rooms are typically sold out long before that date - I encourage you to reserve NOW and adjust reservation as needed later.
Are you interested in being connected with students or residents from other programs that might want to share a hotel room to reduce expenses?
If you answer yes, your e-mail and cell # as noted above will be provided to other interested students so you can connect
Why are you interested in Family Medicine? *
Your answer
Why do you want to attend National Conference? *
Your answer
Typing your Full Name in the Space Below represents your signature. *
By submitting this application, I confirm that all information in the application is accurate and that I am in good academic standing with my school. I understand that this information may be subject to verification.
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service