AAP: Residents

International Elective Award Application

(Sponsored by the AAP Section on International Child Health, Douglas Heiner, MD, FAAP and the AAP Section on Residents)
APPLICATION FORM DEADLINE: September 15 & March 15 GENERAL INFORMATION Please make sure that your program director has also submitted his or her recommendation by the deadline.
Name
Please provide your age.
Please provide Gender.	Female Male
What year will you finish your residency?
PGY
MAILING ADDRESS:
Street
City
State
Zip
Permanent Address, if different than above. (Street City State Zip)
Home Telephone
Office Telephone
Primary E-mail Address (Please use valid e-mail format. ie, name@domain.com)
ELECTIVE ABROAD
Host Country and City/Region
Host Preceptor
When are you leaving for your elective? (Type in this format: MM/DD/YYYY)
When will you return from your overseas elective? (Type in this format: MM/DD/YYYY)
Please provide a general description of your overseas elective:
What is your motivation for seeking such an elective, and how will it affect your career?
What will you do while you are there? Include information on the kind of facility and your objectives.
What kind of preparations have you made for your trip? (Immunizations, Visa(s), passes, housing arrangements while abroad).
If there will be a language barrier, how will you handle it?
You must make arrangements for medical care should you become ill. What preparations have you made?
Please briefly describe any previous international experience you have had?
CERTIFICATION
I, (Resident) hereby certify that all the questions on the application form have been answered completely and accurately to the best of my knowledge. The elective award MUST be made payable to your institution, therefore the check should be made payable to:
I, the applicant, understand that the decision to undertake study abroad is mine alone, and the American Academy of Pediatrics bears no responsibility for any health or safety risks presented by such study.
Provide applicant name as signature:	Date:
Name of Training Program
Name of Program Director
Program Director E-mail Address
Program Director Street
Program Director City
Program Director State
Program Director Zip
Please review for accuracy, since this will be where the check is sent