Grant application form second half year 2015
Seeking ESC support for a COURSE/MEETING
The ESC will provide funding to support a regional or local course or meeting within Europe related to the aims of the ESC.
Application
Please use this application form. Note sections with a maximum word count. Forms will be returned if the word count is exceeded.
Who can apply?
Applicants must be paid-up ESC members.
Applicants should be Europeans. However, a European applicant is allowed to submit a grant for a course that will take place outside Europe.
Deadline
Applications MUST be received at ESC Central office by 31 December 2015.
Budget
A maximum of 5,000 euro per course application can be requested. The ESC may not be in a position to fully fund all applications.
Name of applicant:Birute Zilaitiene
Job title: PhD, M.D, professor, endocrinologist
Address:Eiveniu str.-2, Kaunas, Lithuania, LT-50009
Tel no.:+370 686 49882
E-mail:
Date of submission of this form: 22 of December, 2015
Name of the person responsible for the course/meeting (If different to the person named in box A):
Birute Zilaitiene, PhD, M.D, professor, endocrinologist
Contact details of the person noted in this box B: name of person, job title, address, tel no. email:
Eiveniu str.-2, Kaunas, Lithuania, LT-50009
Tel. No.: +370 686 49882
E-mail:
Title of the course/meeting:Contraceptive issues in chronically ill patients
Comprehensive description of the course/meeting. (Max 200 words)
Contraceptive choices of chronically ill patients have changed over time. Given new developments in the field of medical conditions of safe and effective forms of contraception are available for almost every women with a chronic diseases. When selecting a method, the nature of the medical illness and the expressed desires of the patient must be taken into account. Lithuanian Society of Contraceptology annually organizes conferences to provide the newest data about contraception use. 2016 Scientific Conference "Contraceptive issues in chronically ill patients"is based on a recomendations about specific contraceptive use by women with medical disorders suchas obesity, endocrine, cardiovascular, haematologic, oncologic, neurological, psychiatric, gastrointestinal, hepatobiliary, autoimmune, renal, pulmonary conditions and disabilities. Due to modern medicine in most of these women, ongoing medical management of their conditions is greatly improved, even compared with a decade or two ago. However, their condition may still be seriously exacerbated and this requires effective and safe contraceptive use until pregnancy is desired and the medical condition is stabilized.
When would it start / finish? (Max 20 words)
7 of April 2016/ 7 of April 2016
Where will it take place – country / town, establishment? (Max 20 words)
It will take place in Lithuania,Kaunas,"Park Inn Kaunas" Hotel, Conference centre, Donelaičio str. 27, LT-44240.
Objectives and needs identified. Who will be the audience? (Max 20 words)
The conference is intended to obstetricians, gynecologists, general practitioners, endocrinologists, other specialties of physicians, residents, students, midwives, nurses.
Sector in the area of contraception, sexual and reproductive health.
Family planning and reproductive health.
What outcomes will be measured? List. (Max 20 words)
Hormonal contraception risk. Contraceptive use by women with hypertension, diabetes, obesity, gastrointestinal disease.Combined oral contraceptives: health benefits beyond contraception.
Do you foresee any reasons why this meeting may not happen? (Max 20 words)
No.
Are there other partners or organisations supporting this same course/meeting? If so, list.
Pharmaceutical company "Gedeon Richter".
Have you requested funding from anyone else for this course/meeting? (If yes, please give details of all funding sources you have approached) (Max 20 words)
No.
How much money are you requesting? A maximum of 5,000 euro per course application can be requested. An overview of the budget must be provided here (max 50 words) and a detailed budget should be attached as an appendix to the application form.
We are requesting 2500 euro for lecturer’s and hall’s rent expenses.
- Two lecturers from Europe are invited.We need the support for two lector’s trip and living expenses.
1 st lecturer’s expenses:
- Airline tickets to Vilnius (13 of April 2015 ) and back to home from Vilnius (15 April 2015) 300 euro.
- 2 nights in a 4 star hotel 2x100 euro=200 euro.
Total: 500 euro.
2nd lecturer’s expenses:
- Airline tickets to Vilnius (13 of April 2015) and back to home from Vilnius (15 April 2015) 300 euro.
- 2 nights in a 4 star hotel 2x100 euro= 200 euro.
Total: 500 euro.
1 st lector’s expencies+2nd lector’s expencies= 500 euro+500 euro= 1000 euro.
- The support is necessary for the hall’s rent:
- The theatre-style conference hall for up to 350-400 persons’ rent= 1000 euro.
- Multimedia projectors and screen rent= 300 euro.
- Microphone rent= 100 euro.
- Computer rent= 100 euro.
Total cost: 2 lector’s expencies 1000 euro + hall’s rent expencies 1500 euro=2500 euro.
Have you already obtained any funding towards this course/meeting? (If yes or still awaiting a response, please give details) (Max 20 words).
We already obtained 500 euro support from pharmaceutical company "Gedeon Richter" for welcomes coffe expenses.
Who will oversee the budget & keep accounts?
Virginija Vanagienė, the president of Lithuanian Society of Contraceptology.
I / We, as responsible agents for this course/meetings, agree to the following 6 points:
I/We agree that all monies will be spent appropriately / YESI/We agree to advise you at the earliest time if this course/meeting is delayed or cancelled / YES
I/We agree to provide a report to the ESC within 6 months of the end of the course/meeting / YES
I/We agree to present the ESC treasurer with a detailed budget at the end of the course/meeting. / YES
/We agree that if you need to make any significant changes to the funding of the project after it has been awarded, I/we will advise the ESC Treasurer. / YES
I/We agree to acknowledge the ESC as a donor in any publications and oral communications resulting from this course /meeting. / YES
Signed Date
Name
Please return this form (by email) to:
ESC Central Office
Opalfeneweg 3
B-1740 Ternat, Belgium
Tel +32 2 582 08 52
Fax +32 2 582 55 15
1