Kathy Cramer Young Clinician Memorial Scholarship Award

Through a generous donation from the Estate of Kathy Cramer, OTA is pleased to announce a scholarship award for young clinicians. Through the Kathy Cramer Young Clinician Scholarship Award, OTA will sponsor two OTA members for participation in the ORS/OREF/AAOS Young Investigators Workshop.

2016ORS/OREF/AAOS New Investigator Workshop

Clinical, Translational, and Basic Science Research

WORKSHOP APPLICATION

May 13-14, 2016 ● Jacksonville, FL

Application Deadline: February 1, 2016.

Please email this application and all supporting documents to

(DO NOT PDF YOUR DOCUMENTS)

►Completed Application

►Letter of Nomination

►NIH Biosketch of the Applicant (Template)

►Profile Page

►Housing/Registration Form (Please note, your credit card will only be charged if your application to attend is accepted)

First Name / Last Name
Credentials
Institution
Department
Address 1
Address 2
City / State/Province
Zip/Postal Code / Country
Email / Phone#
ADDITIONAL INFORMATION
Research Collaborations
OREF Grant Recipient? / YES NO
If yes, what year?
Do you plan to submit a grant proposal? Accepted grant proposals are K, R01, R03, R 21 / YES NO
If yes, please email your proposal to byFebruary 15, 2016
NIH Style Specific Aims Page / REGUIRED!
You must bring NIH style specific aims page of a proposed research grant or one that was just funded that has not begun.

2016ORS/OREF/AAOS New Investigator Workshop

Clinical, Translational, and Basic Science Research

PROFILE PAGE

This page will be published in the workshop’s syllabus

pending your application acceptance.

Photo

Please upload your high resolution photo (minimum 300 dpi)

Double click on the image icon to upload your photo

,

First Name Middle Initial Last Name, Degree

Position Title:

Current Institution:

Personal Statement (250-300 words)

Career Goals (250-300 words)

Orthopaedic Areas of Interest

2016 REGISTRATION / HOUSING FORM

Please return this form to the OTA office by February 1, 2016.

Fax: 847-430-5140 or Email:

2016 ORS/OREF/AAOS New Investigator Workshop

MEETING DATES:Friday - Saturday, May 13-14, 2016

MEETING SITE:Hyatt Regency Jacksonville – Riverfront

Friday, May 158:00 am – 5:30 pm

Saturday, May 168:00 am – 3:00 pm

HOUSING SITE: Hyatt Regency Jacksonville – Riverfront, Jacksonville

225 E. Coastline Drive, Jacksonville, FL 32202

Phone: (904) 588-1234

Check-in Time: 3:00pm, Check-out Time: 12:00pm

PARTICIPANT INFORMATION

YOUR NAME
EMAIL
List any food allergies or indicate if you are a vegetarian

$775 REGISTRATION FEE INCLUDES:

  • Housing ( 2 nights: Thursday, May 12 and Friday, May 13)
  • Meals provided on Friday, May 13 and Saturday, May 14
  • Networking and Collaboration Dinner (Casual)
  • Workshop materials

CREDIT CARD INFORMATION:
American Express VISA MasterCard
Credit Card #: Exp Date:
Print Name of Card Holder:
Signature of Card Holder:
Room rate of $139 will be honored May 11-15 if you plan to arrive early or extend your stay. This room rate excludes of taxes, currently at 14.13%, resort charges, and service charge.

NOTE: Attendee is responsible for incidentals, all spouse/guest expenses, and any extra night(s) at the hotel not related to the workshop

SLEEPING ACCOMMODATIONS

Arrival Date: / Departure Date:
Smoking Single Occupancy King Bed
Non-Smoking Double Occupancy Double Bed
If ADA (Americans with Disabilities Act) accommodation is desired, please specify:

All reservations are guaranteed for late arrival (after 6:00 PM) by the Orthopaedic Research Society.

If you request a sleeping room and fail to notify the staff liaison or hotel directly of a cancellation prior to 11:00 AM of the day of arrival, you will be billed for one night’s sleeping room cost by the ORS.

FRIDAY, MAY 13, 2016:NETWORKING & COLLABORATION DINNER

You are invited to the networking and collaboration dinner on Friday evening (6:30pm – 9pm) for all faculty and participants.

I WILL ATTEND I WILL NOT ATTEND

SATURDAY, MAY 14, 2016:WORKING LUNCH, MEETING WITH MENTORS, NETWORKING & COLLABORATION

I WILL ATTEND I WILL NOT ATTEND (I have an early flight)

PLEASE COMPLETE AND RETURN THIS FORM BY FEBRUARY 1, 2016

TO: Barbara Shozda

FAX: 847/430-5140E-MAIL:

If you have questions, please call the OTA office at 847-430-5137.