Name: Click here to enter text.
Gender: Click here to enter text.
Street Address: Click here to enter text.
City: Click here to enter text.
State: Click here to enter text.
Zip: Click here to enter text.
Phone: Click here to enter text.
Email: Click here to enter text.

Please indicate your current educational program:

☐ Resident/Trainee

☐ Medical student

☐ Year I

☐ Year II

☐ Year III

☐ Year IV

☐ Year V

☐ Graduate student

☐ Undergraduate student

☐Other

Discipline: Click here to enter text.

Current University: Click here to enter text.

Expected Date of Completion of Training: Click here to enter text.

  1. Previous Educational History

University / Degree / Graduation Year
  1. Country of Residence Click here to enter text. (If different from current country of training)
  1. Have you ever applied for the SAHM Edie Moore Student Travel Scholarship?

☐ Yes ☐ No

Dates of past applications: Click here to enter text.

  1. Have you ever received the SAHM Edie Moore Student Travel Scholarship?

☐ Yes ☐ No

  1. If you are currently enrolled in a fellowship training program, does your program offer any financial support for your attendance at the SAHM Annual Meeting? If so, how much funding do they offer?
  1. Are you planning on attending the 2018 SAHM Annual Meeting, even if you are not funded through this Scholarship?

☐Yes ☐ No

  1. Did you submit an abstract for the 2018 SAHM Annual Meeting?

☐ Yes ☐ No

If so, what is the reference number? ______

  1. Please list the courses you have taken in school that relate to adolescents and adolescent health:
  1. Please list any clinical work you have done that relates to adolescents and adolescent health:
  1. Please list any community service you have done that relates to adolescents and adolescent health:
  1. What are your educational and career goals? (70 Word Maximum)

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  1. Please describe your interest in adolescent health: 70 words max)

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  1. Please describe your interest in SAHM: (70 words max)

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  1. Explain your desire to join SAHM and/or obtain mentorship in adolescent health or medicine: (70 words max)

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  1. What information or experience are you looking to gain from attending the SAHM Annual Meeting? (70 words max)

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Society for Adolescent Health and Medicine
One Parkview Plaza, Suite 800 ♦ Oakbrook Terrace, IL 60181 ♦ +1-847-686-2246♦