Registered Charity No. 210183
PAPERS MUST BE TYPEWRITTEN AND MUST NOT BE FOLDED.
APPLICATIONS MUST BE COMPLETED IN FULL:
INCOMPLETE OR INCORRECTLY COMPLETED FORMS WILL NOT BE CONSIDERED.
Q1 / Personal Details of Candidate(a) / Full name of candidate:
(b) / Date of birth:
(c) / Male of Female:
(d) / Full address of MedicalSchool (where full-time undergraduate:
(e) / Year medical course commenced:
(f) / Have you ever undertaken an intercalated degree course in a biologocal subject?
If YES, please specify:
(i) Institution where award was held:
(ii) The subject and class of degree awarded: / YES/NO
Q2 / Signatories
(a) / Dean of nominating Medical School
I support this application without reservation, and consider the proposed place of study to be appropriate for the project, and the proposed project to be suitable for the candidate.
Name: / Date:
Signature of Dean:
(b) / Secretary/Finance Officer of Institution
If a grant is made I will ensure that the funds provided are used for the purpose for which they have been given.
Name: / Date:
Position: / Signature:
Q3 / Research Project
(a) / Title of project (not more than 200 characters
(b) / Aims of project (not more than 100 words):
(c) / Plan of investigation (not more than 600 words): please give an outline of the proposed project to include:
(i) background of the project, (ii) details to the research project, (iii) reasons for choosing the project.
Q4 / Period for which support is sought:
(state dates)
Q5 / Details of Support Requested:
Please complete the table below, giving details of support requested and the corresponding cost.
The maximum award is £1,600 (up to £1,000 for Personal support and £600 for Research expenses). Note that requests for personal support should be for out-of-pocket expenses that would not be otherwise incurred.
(a) / Personal support (up to a maximum of £1,000)
(i) / Travel costs
Subtotal
(ii) / Other expenses (accommodation, subsistence, and health insurance. Note that health insurance can only be requested for those wishing to visit non-EU countries).
Subtotal
(b) / Research expenses (up to a maximum of £600)
Subtotal
Total cost requested
(c) / Do you plan to undertake this project with a fellow elective student?
If YES, please give his/her:
(i)Name:
(ii)Details of financial support: / YES/NO
Q6 / Recommendation of Candidate by a Named Tutor:
Name: / Date:
Position: / Signature:
Wellcome Trust Student Elective Prize Application
This page must be completed by the proposed supervisor at the host institution: i.e. where elective study is to be carried out. PLEASE NOTE THAT THE APPLICATION CANNOT BE CONSIDERED UNTIL THIS SECTION HAS BEEN COMPLETED BY THE HOST INSTITUTION.
Q7 / Details of Host Institution(a) / Name of proposed supervisor at host institution:
(b) / Position:
(c) / Full address of proposed host institution:
(d) / Supervisor at host institution
I shall actively be engaged in the day to day control of the project, and can confirm that the proposed project has been prepared in consultation with the candidate. I also confirm that, where appropriate i) procedures are authorised under legislation relating to the use of animals in experiments and, or, ii) local ethical permission has been obtained or is being sought.
Signature of supervisor: / Date:
(e) / Head of department where research will be carried out.
I can confirm that I have read and support this application and I agree to this research being carried out in my department and that all the necessary licences and approvals have been obtained or are being sought.
Name: / Date:
Signature:
Wellcome Trust Student Elective Prize Application