North Carolina Travel Stipend Application
Personal Information
Name: / Click here to enter text.
Email Address: / Click here to enter text.
MCH Degree Program: / Click here to enter text.
Year in Program: / Click here to enter text.
Practicum Location: / Click here to enter text.
Conference Attending (if applicable): / Click here to enter text.
Location and Date (if applicable): / Click here to enter text.
Presentation or Practica Description (please limit to one page or less)
If requesting funds to subsidize your practicum experience, include:
· agency name
· summary of the work to be completed
· expected findings or outcomes of your experience
If requesting funds to present information on your work:
· include summary of your data, methods, findings, and implications
· note any co-authors
· highlight how your findings may inform public health practice in North Carolina or how your presentation would disseminate findings about North Carolina-based work.
These travel funds are only available to support a practica or presentation of North Carolina-related work in a public health service delivery site (i.e., work taking place in North Carolina, and if applicable, subsequently presented in North Carolina). Funding for national presentations and/or global work is often available from UNC Global and other sources.
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Justification of Funds
Please state the amount of funds you are applying for (up to a maximum of $250). Provide a budget and justification for the amount requested (e.g., travel, lodging, etc). The MCH Alumni Committee reserves the right to decide on the amount awarded to an individual. The awarded amount may not equal the requested amount. Awards will be paid based upon University guidelines and state allowances.
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Submit completed form to Joseph Lee, MCH Alumni Committee Treasurer at as well as Julie De Clerque, MCH Alumni Committee President at .
Questions may be directed to the same addresses.
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MCH Alumni Committee Travel Awards 2016-2017, rev Sept 7, 2016 jdec