SECTION ON NEUROLOGY - VISITING PROFESSORSHIP APPLICATION FORM

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Visiting Professorship Application
Institution Name:
Institution Address:
Institution City:
Institution State:
Institution Zip:
Total Number of Residents
Total Number of Medicine/Pediatric Residents (not included in above amount)
Department Chair:
Department Chair E-mail:
Department Chair Address:
Department Chair City:
Department Chair State:
Department Chair Zip:
Department Chair Phone:
Program Director Name:
Program Chair E-mail:
Program Director Address:
Program Director City:
Program Director State:
Program Director Zip:
Program Director Phone:
Statement of educational needs to be met by the visiting professor

Describe any existing pediatric neurology resources within your institution (ie, do you have a child neurologist or expert in pediatric neurology affiliated with your organization?)

Names and institutional affiliations of 3 candidates for the visiting professorship. List in order of preference. (If you need assistance in identifying nominees, a list of possible candidates is available upon request from Ms. Drelicharz at: bdrelicharz@aap.org)

Aniticpated format of the visit. Please provide a complete and detailed program schedule.

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