Travel Grant Application

HAFP Foundation Medical Student/Resident Travel Grant Application

Date *

Name *

Email *

Medical School/Residency Program *

Class Standing (i.e., MS1, OMS1, PGY1) *

AAFP Member # *

Log into your AAFP profile if you do not know your AAFP Member # (https://www.aafp.org/home.html)

Address (check will be mailed to this address) *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Event *

AAFP National Conference of Medical Students and Residents (July)
AAFP Chief Resident Leadership Development Program
AAFP Family Medicine Advocacy Summit (May)
Other (Describe below)

If Other was chosen, please describe:

Event Start Date: *

Event End Date *

Purpose for Attendance *

Please explain why you are attending this event (e.g., you have been accepted to present a poster or oral abstract; you are receiving an award; you would like to further your leadership knowledge, etc.)

Amount Requested (maximum of $1,000) *

Other Funding Sources (if applicable)

Please provide details of other funding sources (if applicable) for this event, such as program funding, other grants, etc.

If awarded, I give HAFP Foundation permission to use my photo and event report in HAFP member materials, such as newsletters, website, etc. *

Agree

Upload photo

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Upload CV/Resume

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