Regional Meeting Grant Application

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Part I: Contact Information

At least 3 institutions need to participate in this meeting. Please include name and contact information for each institution below:
Participating Institution 1*
Participating Institution 2*
Participating Institution 3*
Are there additional participating institutions?*
- Yes
- No
Additional Participating Institutions
Please list names and contact information for all additional participating institutions here.
Amount Being Requested*
Name of Regional Meeting Program Chair*
First Last Suffix
This is the person to be contacted about the grant.
Email of Regional Meeting Program Chair*
Phone of Regional Meeting Program Chair*
Name of Regional Meeting Admin/Finance Contact*
First Last Suffix
Email of Regional Meeting Admin/Finance Contact*
Phone of Regional Meeting Admin/Finance Contact*
Name of Regional Meeting CME Contact*
First Last Suffix
Email of Regional Meeting CME Contact*
Phone of Regional Meeting CME Contact*
Part II: Meeting Details
Meeting Start Date*
MM slash DD slash YYYY
Meeting End Date*
MM slash DD slash YYYY
Meeting Location*
Street Address Address Line 2 City State ZIP Code
Are Fellows invited to this meeting?*
- Yes
- No
How will Fellow presentations be organized?
Are Residents invited to this meeting?*
- Yes
- No
Are medical students invited to this meeting?*
- Yes
- No
Will the award be used to defray the cost of Fellow, Resident or medical student registration?*
- Yes
- No
Will the award be used for refreshments for the Fellow presentations?*
- Yes
- No
Part III: Speaker Information
Name of Invited Speaker*
First Last Suffix
Address of Invited Speaker*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email of Invited Speaker*
Phone of Invited Speaker*
Topic or Title of Lecture*
Are there additional invited speakers?*
- Yes
- No
Provide information for additional speakers:
Part 4: Written Report

To learn the outcome of these meetings, a written report must be submitted within the 2 weeks following the meeting. The feedback report should include a copy of the program accompanied by a brief written report about the meeting with information regarding attendance, composition of the audience, and the name of the outside speaker. This report should include details regarding fellow, resident, and medical student presentations and participation.
Name of Person Submitting Application*
First Last Suffix
Date of Submission*
MM slash DD slash YYYY

Part I: Contact Information

Part II: Meeting Details

Part III: Speaker Information

Part 4: Written Report

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