.jpg?n=9140 "Charitable Foundation Logo")
Information for Applicants
Complete the application below. Deadline for submission is September 15 at 4:00 p.m.
Summary of the IHS Grant Program
Instructions
Complete all of the fields below, noting the character limits, and then click the “submit” button. You must also email to foundation@mms.org a PDF of a letter of support on institutional letterhead, from your supervising faculty, attesting that you are in good standing at the medical school or residency program and that the international project has been approved and will be supervised.
All fields marked with an * are required.
Part I. Applicant Information
I am a:* Year:* Specialty (for residents):
Please detail your past international activities. Include the name of the organization or program with which you traveled, if applicable, and the length of your experience.* (750 characters max)
| Name of faculty (dean, advisor, or supervisor) at your institution who has approved this elective or project:* |
|
| Mailing Address:* |
|
(Your application is not considered complete until you email to foundation@mms.org a PDF of a letter of support on institutional letterhead, from your supervising faculty, attesting that you are in good standing at the medical school or residency program, and that the international project has been approved and will be supervised.)
Part II. Elective or Project Abroad
| Host country/city/region:* |
|
| Host institution:* |
|
| Mailing Address:* |
|
| Office Phone:* |
|
| Website Address:* |
|
| Host preceptor:* |
|
| Mailing Address:* |
|
| Office Phone:* |
|
| Email Address:* |
|
How will you use this grant, if awarded?* (250 characters maximum)
Is your participation in this program funded by any other scholarships or grants?*
Have you applied, or do you plan to apply, for any other funding for this program?*
If other funding is awarded for participation in this program, I agree to notify the Foundation within 14 days of the funding decision and provide the amount and source of award.*
Identify the type of facility (hospital, clinic, etc.) at which you will work:* (500 characters maximum)
Describe the population of the community in which you will be working:* (750 characters maximum)
Will there be a language barrier? How will you communicate with staff and patients?* (250 characters maximum)
If you are a medical student, please put NA or Not Applicable in the following two questions and then skip to PART III.
Describe the needs of the community in which you will be working. If you are a medical student, please put NA in this field. (1,000 characters maximum)
What services will you provide as part of your participation in this program and how will your experience improve the health of the community you plan to serve? If you are a medical student, please put NA in this field. (1,250 characters maximum)
Part III. Personal Statement
Please include a brief summary of your career plans and how this experience will complement those plans.* (2,500 characters maximum)
Please check the boxes to indicate that you have read the information below.
* I agree to submit, within sixty (60) days of completion of this project, a report to the Massachusetts Medical Society and Alliance Charitable Foundation (foundation@mms.org) outlining important outcomes and “lessons learned” from my experience, along with relevant photographs and required receipts. I understand that grant monies will be awarded upon satisfactory receipt of required documentation, which includes a letter from my supervising faculty attesting to my completion of the program.
* By clicking submit below, I agree that I have signed and submitted this application.
