BURSARY PROGRAM

APPLICATION FORM

Deadline: December 31st, 2017

Eligibility:

Individuals who are at least 18 years of age on August 6th, 2018 and requirepart or full financial assistance to attend the 14th Global Conference on Ageingare eligible to submit an application for consideration.

Please note that applicants must have submitted an abstract before applying for the Bursary Program and must be registered for the conference before submitting an abstract.

Preference will be given to potential attendees who reside incountries/regions other than Canada, United-States, Israel, Japan, Australia, New Zealand and Western Europe.

Please return the completed Bursary Program application form to:
Email: / Mr. Greg Shaw
Director, International & Corporate Relations

Ms Tarah McMster
Conference and Events Coordinator

Mail: / Conference Bursary Program
International Federation on Ageing
1 Bridgepoint Dr
Suite G.238
Toronto, ON
M4M 2B5

1. Personal Information

Title / First Name / MiddleName / Last Name
Passport Country of Issue
Gender Male Female
Passport number:
Date ofissue: / Date of expiry:

IFA Membership (if applicable)

Yes Membershipnumber: ______
No

2. Contact Information

Street/PO Box Address / Apt. / City
State / Province / Postal Code/Zip Code / Country
Email
Preferred Phone No.
Fax
Preferred method of be contact: Email Phone Fax

3. Emergency Contact

Person to contact in case of an emergency

Name / Relationship
Email / Telephone

4. Occupational Status

Check the box that applies

Employed
Student
Dependant (family or government) / Unemployed
Non-remunerated activities (volunteer…)
Retired
Name of Institution (if any)

5. Request for Partial and / or Full Financial Assistance

Financial assistance needed for:
Travel Hotel Registration
Accommodation:
NB A maximum of 4 nights’ accommodation can be provided under this support package.
Accommodation needed for:
Tuesday, August 7th, 2018
Wednesday, August 8th, 2018
Thursday, August 9th, 2018
Friday, August 10th, 2018
City of Departure: / Country of Departure:
Preferred Departure Date: / Preferred Return Date:

6. Involvement in the Field of Ageing

Check and complete all that applies:

Sector / Organization Name / Position Held
Government
NGO
Private Sector
University
Individual/No Affiliation
Health Care Professional
Residential Care Provider
Community Care Provider
Carer/Caregiver
Researcher
Other
Student / Field of Study:

7. Conference Experience

Have you previously attended a past IFA Global Conference on Ageing?
YesNo
If so, which conference/conferences?
Brisbane 2016 Hyderabad 2014Prague 2012
Have you submitted an abstract to be a presenter at the conference? Yes No
Title of the Abstract:

8. Short Answers

In the space below, answer the following questions (200 words or less per question):

  1. Why do you want to attend the IFA’s 14th Global Conference on Ageing?
  2. What are the specific objectives and outcomes you have for attending the Global Conference?
  3. Please detail the need for financial assistance and providedetails of costs that you may be able to cover.

9.Terms and Conditions

The undersigned applicant for the Bursary Program confirms that the aforementioned information is accurate and has not misrepresented themselves in any capacity. The applicant understands that if any of the information provided is found to be faulty or misleading, they will be ineligible for financial support through the Bursary Program. If funding was provided and spent, the applicant will have to refund the IFA for the complete amount spent and any potential legal fees associated.

10. Signature and Declaration

I have read and understood the terms and conditions of the Program and agree to:

  • abide by the eligibility outlined for the Conference Bursary program;
  • provide additional information, if deemed necessary;
  • provide proof that I am holding a valid passport enabling me to travel to Canada for the entire period of the event;
  • apply for a Canada travel visa immediately following Bursary approval acknowledging that ticketed airline travel will not be provided without proof of having obtained a Visa to travel to Canada (if applicable).

I hereby declare that all the information on the application form is complete and true to the best of my knowledge.

Applicant’s Signature / Date

Applications must be accurate and complete to be considered for the Bursary Program. Applications which are incomplete will be automatically rejected.