2012-13 Faculty of health sciences
Study abroad support fund
APPLICATION FORM
Award Description:
The Faculty of Health Sciences Study Abroad Support Fund is a competitive award designed to provide financial assistance to students engaged in academic study and/or practice education placements in an international setting. The award program is linked to the University and Faculty’s strategic objective to increase outgoing international opportunities for Faculty of Health Sciences students.
Value of Award:
· Dependent upon available funding and the number of eligible applicants
· Will not exceed $500 (CDN)
Eligibility:
· Full-time students registered in the Faculty of Health Sciences
· International student experiences to be supported must be recognized and approved at the School/Program level
· The student experience must be part of an academic course, a research/research lab placement, or practice education placement
Process:
· Complete the Faculty of Health Sciences Study Abroad Support Fund application form (attached)
· Award period: September 1, 2012 to August 31, 2013
· School/Program Application deadline: March 8, 2013
· Applications are initially reviewed and prioritized at the School/Program level with recommendations presented to the Faculty of Health Sciences International Committee (FHSIC) for final decisions
· School/Program recommendations are forwarded to the FHSIC by March 29, 2013
· FHSIC decisions on funding: April 19, 2013
Additional Information:
Dr. Darwin M. Semotiuk, Chair
FHS International Committee
Telephone Number: 519-661-3088
E-mail:
Personal Information (Please Print)
Name: ______Student #: ______
Social Insurance (SIN) #: ______Date of Birth : ______Male: ___ Female: ___
(D/M/Y)
Program/School: ______Current Year of Registration: ______
Mailing Address (for reimbursement cheque): ______
______
Telephone Number: ______E-mail Address: ______
Are you /have you been employed by Western? Y __ N __ UWO Employee # ______
Supporting Documentation:
Briefly outline below:
1. The international experience for which you are requesting funding (e.g. course number, location, placement site, etc.). ______
______
2. The length of the experience (i.e. days/weeks/months) ______
3. The anticipated or actual costs incurred. ______
______
4. Other funding sources applied for: ______
______Amount: ______
5. Other funding sources confirmed or received ______
______Amount: ______
Ambassadorial Statement:
1. Describe how you will act as an ambassador for your School, Faculty and University while participating in this international academic study and/or practice education placement.
______
______
______
______
______
______
Signature: ______Date: ______
Completed applications (hard copy preferred) should be submitted to your FHSIC School/Program Representative:
School of Health Studies: Dr. Deborah Fitzsimmons ()
School of Communication Sciences & Disorders: Prof. Susan Schurr ()
School of Kinesiology: Dr. Alan Salmoni ()
School of Nursing: Dr. Yolanda Babenko-Mould ()
School of Occupational Therapy: Prof. Ann Bossers ()
School of Physical Therapy: Prof. Ann MacPhail ()
Note: Western University is committed to protecting the privacy of personal information. The above information will be used, maintained, disclosed and disposed of in accordance with the applicable provincial or federal legislation.
Students with Financial Need
In addition to the FHS Study Abroad Award, I wish to be considered for a needs-based award as well.
Special Circumstances: In a separate letter, please outline any special or extenuating circumstances, which must be documented, that you would like the Dean’s Office to consider as we review your application.