One resident should be identified as the project leader for this
award and should be a member of the AAP. That person should complete all
questions. (Residents may work as a team on the application but identifying
a single project leader is necessary from a logistical standpoint.) Applications
will be judged on the basis of resident or medical student involvement,
project sustainability, originality, and overall impact on child health.
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APPLICATION FORM
DEADLINE: July 1, 2008
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GENERAL INFORMATION
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Project Leader's Name
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| MAILING ADDRESS: |
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| Street |
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| City |
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| State |
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| Zip |
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Permanent Address,
if different than above.
(Street City State Zip) |
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| Home Telephone |
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| Office Telephone |
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Primary E-mail Address
(Please use valid e-mail format. ie, name@domain.com)
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Co-Leader's Name
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| Co-Leader's MAILING ADDRESS: |
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| Co-Leader's Street |
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| Co-Leader's City |
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| Co-Leader's State |
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| Co-Leader's Zip |
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Co-Leader's Permanent Address,
if different than above.
(Street City State Zip) |
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| Co-Leader's Home Telephone |
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| Co-Leader's Office Telephone |
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Co-Leader's Primary E-mail Address
(Please use valid e-mail format. ie, name@domain.com)
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ADVOCACY PROJECT
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| Project Title |
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Please provide a general description of your child advocacy project, including the need being addressed by the project:
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Please provide a short history of the project? How long has the project been in existence?
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Did you create this program?
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YES
NO
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Is this project considered as your community pediatrics rotation, as part of your residency training?
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YES
NO
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Describe roles of residents in the project.
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Describe roles of faculty in the project.
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Are you receiving funding from other sources for this project?
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YES
NO
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Please elaborate on funding from other sources.
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What plans (if any) have been made for the continuation of the program after you graduate?
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CERTIFICATION
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Please send a letter via e-mail from your faculty sponsor or residency director in support of this application to: Kimberley VandenBrook (kvandenbrook@aap.org ) by the July 1, 2008 deadline.
I, (Project Leader) hereby certify that all the questions on the application form have been answered completely and accurately to the best of my knowledge.
If I receive the award, the $300 honoraria check will be used for the project named above, and the check should be made out to: (Checks can be made out to individuals or institutions. Please note that you will receive a tax statement from the AAP if you receive $600 or more from the AAP in the calendar year.)
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Name of Training Program
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| Name of Program Director |
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| Program Director E-mail Address |
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| Program Director Street |
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| Program Director City |
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| Program Director State |
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| Program Director Zip |
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| Name of Department Chairperson: |
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