Dr. Barry Adams Paediatric Resident Advocacy Education Grant
Dr. Barry Adams Paediatric Resident Advocacy Education Grant
APPLICANT INFORMATION
Name
Name
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First
Last
Membership Number
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Phone
Phone
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Email
Institution
Training
*
Medical Student
Paediatric Resident
Paediatric Fellow
Training Year
*
1
2
3
4
5
If fellowship or 4th year, please specify specialty
Academic Paediatric Medicine
Adolescent Medicine
Allergy-Immunology
Ambulatory Paediatrics
Biochemical Diseases
Cardiology
Child & Youth Maltreatment
Clinical Pharmacology
Critical Care
Departmental Clinical Fellowship
Dermatology
Developmental Paediatrics
Emergency Medicine
Endocrinology
Gastroenterology
Genetics
Haematology-Oncology
Infectious Diseases
International Health/Adoption
Neonatal Transport
Neonatology-Perinatology
Nephrology
Neurology
Oncology
Paediatric Multiorgan Transplant
Respirology
Rheumatology
Sports Medicine
Please provide a narrative biographical sketch of applicant
*
Please list all members of the project team.
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PROGRAM INFORMATION
Program Director or project supervisor: name and title
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Institution
*
Phone# of supervisor
Phone# of supervisor
*
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Email of supervisor
*
PROJECT INFORMATION
Please answer the following questions (maximum 300 words per question):
Project Title
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Project summary: What is the project's main focus or area of interest?
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Maximum of
300
words allowed.
Currently Entered:
0
words.
Describe the target community/population for this project/program.
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Maximum of
300
words allowed.
Currently Entered:
0
words.
Clearly identify the impact and scope of the research or advocacy work.
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Maximum of
300
words allowed.
Currently Entered:
0
words.
Goals: Outline the short-term goals of this project and how they will be measured.
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Maximum of
300
words allowed.
Currently Entered:
0
words.
Goals: Explain the long-term goals (beyond grant) of this project and how they will be measured.
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Maximum of
300
words allowed.
Currently Entered:
0
words.
Why should this grant be used to fund this project? (e.g., summarize and justify the need for funding)
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Maximum of
300
words allowed.
Currently Entered:
0
words.
Explain how the project will be sustained beyond the grant period.
COMMUNITY COLLABORATION
Identify any community partners, organizations or others that you plan to work with and what their role is for the project.
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Maximum of
300
words allowed.
Currently Entered:
0
words.
PROJECT BUDGET
Attach a table outlining the major project activities, with timelines.
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Attach Files
Word, PDF, or Excel format
Attach the estimated budget for this project. Please include detailed line items and identify any other sources of funding and the amounts. Please clearly indicate the amount of funding you are requesting from Healthy Generations.
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Attach Files
Attach Letter(s) of support. Letter(s) should be from a program director, the organization you are working with, or someone in a leadership position who can vouch for the project.
*
Attach Files
(word, pdf).
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