Closing date: 4pm,Monday 24July, 2017

APPLICATION FORM

Applicants are required to submit anoriginal signedapplication form andfive (5) double-sided photocopiesby the closing date to:Research Grants Officer, Research Secretariat, Level 2, Samuel Way Building, WCHN (WCH campus).

Applicants are also required to send anelectronic version(as a Word document) via email by the closing date to:

If necessary, adjustthe text boxes to accommodate your response. Additional information may be submitted on separate sheets. Please ensure these are included in the single electroniccopy.

Name:
(title/first/surname)
Home Address:
Suburb / State:
Post Code
Work Address:
Dept / Division:
Floor/Building/Zone:
Contact details
Telephone Home:
Work:
Mobile:
Email:

EDUCATION HISTORY

State highest educational standard attained and any degrees, diplomas or certificates received or being sought and the dates they were awarded or are expected to be awarded.

Degree, diploma, certificate received or being sought / Date received or expected to be received / Institution / Location

EMPLOYMENT HISTORY (in brief)

PRESENT POSITION(and length of service at the Women’s and Children’s Health Network)

PUBLICATIONS AND MAJOR PRESENTATIONS(list allwithin the past five years)

COMMUNITY AND/OR PROFESSIONAL SERVICE(summarise briefly community and/or professional service and other activities outside your regular occupation)

FELLOWSHIP DETAILS

Type of Application: Research Short course Professional Development

NB: If attending a conference, preference will be given to applicants who are presenting a paper and/or a poster at the conference, and evidence of abstract acceptance should be provided with this application.

Provide a lay language summary of the activity you are proposing (No more than 300 words) for use in promotional materials by the WCH Friends / WCHN.

Describeconcisely each of the following three points:

a)Your reasons for applying for the Fellowship,

b)The aims of your Fellowship,

c)The nature and scope of your proposed research / short course/professional development activity.

No more than 600 words.

If proposing to undertake a Study Tour (national or international) to visit organisations and their services/clinics/programmes, the applicant must provide evidence of:

a)How the organisation(s) have demonstrated improved outcomes for their consumers, and

b)How the Study Tour will be beneficial and translatable to the SA community, taking into account resources required for implementation by WCHN.

VALUE TO POSITION AND WCHN (Describe the value of this Fellowship to you and WCHN, and how you intend to apply outcomes upon your return to WCHN, including any costs associated with implementation of outcomes)

DISSEMINATION STRATEGIES(Describe how you intend to pass on the information gained to your colleagues at WCHN, others in your field and to the WCH Friends / WCHN)

Budget (Detail the costs you wish covered by the Fellowship and state those costs which will and/or may be met from other sources if applicable e.g. Departmental support).

NB: Must provide supporting documentation as attachments, including conference information, abstract submitted/ accepted, travel costs/quotes, research program details, professional development details, course fees etc.

In addition, all travel arrangements must adhere to the WCHN and SA Health travel policies.

Total Amount sought______$

DATES

Date of proposed activity:
If travel is required
Date of proposed departure:
Date of proposed return:
Total period of Fellowship: / (days)

APPLICATION CERTIFICATION AND ENDORSEMENT:

Certification by applicant:

I certify that all details in this application are correct and agree to undertake the activity in accordance with the guidelines and relevant policies (such as the WCHN and SA Health travel policies)

I have discussed this application with my manager/department head/divisional director/executive director (as applicable) who supports the content of my proposal.

Signature: ______

Date: //(dd/mm/yy)

Endorsement of Application

All applications submitted must be endorsed by the Department Head, Divisional Director and Executive Director after ensuring they are all aware of the specific content. In so endorsing the application, all signatories acknowledge consent and support for the application and budget provision for backfill if required during the period of the Fellowship.

Department Head

Name: ______

Signature: ______

Date://(dd/mm/yy)

Divisional Director

Name: ______

Signature: ______

Date://(dd/mm/yy)

Executive Director

Name: ______

Signature: ______

Date: //(dd/mm/yy)

WCH Friends Fellowship Application Formpage 1