RANZCOG

Women’s Health Foundation

ResearchScholarships, TravelGrantsFellowships

Closing Date for Applications: 30 June 2018

Please indicate ALLtravel-based fellowships and grants for which you are eligible*andwish to be considered:

ASGO Travelling Fellowship – National

Beresford Buttery Travel Grant

Brown Craig Travel Fellowship

Miriam O’Connor Travelling Scholarship#

RANZCOG NSW Regional Committee Travelling Scholarship

*Eligibility criteria must be met at the time of application, not at the time of commencement of the proposed travel.

#Additional questions apply.

SECTION 1 – APPLICANT

Applicant Details

Title SurnameGiven Names (in full)

State and Country of Residence:

If you are nota RANZCOG member, please provide your preferred contact details below:

Telephone Email

Your association with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) and/or Australian Society of Gynaecologic Oncologists (ASGO):

RANZCOG Trainee / RANZCOG Fellow
ASGO Member /
Other(please list)

Academic Qualifications

Undergraduate Degree / DiplomaInstitutionDate of Award

Undergraduate Honours (if applicable)

Higher Degree (enrolled or completed)InstitutionDate of Enrolment/Award

Current Training Information (if applicable)

Fellowship Training ProgramInstitutionYear of Training

Current Post and Appointments over the Past Two Years

Current (Position, Hospital/Institution, Duration)

Previous (Position, Hospital/Institution, Duration)

section 2 – proposed study/travel/PRESENTATION

For funding to assist with travel for the purpose of study/work, complete PART A, for funding to assist with the presentation of a paper at a scientific meeting, complete PART B.

PART A:Details of the Proposed Period of Overseas Study/Travel

Institution/Centre(s) to be visited

Institution
Department
Address
Supervisor
Institution (2)
Department (2)
Address (2)
Supervisor (2)

Objective of the Program

Details of program at centre(s) to be visited

How findings from visit will be reported

Duration of study visit (including proposed dates, if available)

Salary

How will your salary be covered to enable you to pursue your travel/study?

Miriam O’Connor Travelling Scholarship

If applying for the Miriam O’Connor Travelling Scholarship, this application must be accompanied by a letter confirming approval of the position by eitherthe host Ministry of Health (MoH),a recognised volunteer organisation or an organisation that conforms with the minimum standards of the Sphere Project (

Name of Organisation

Letter attached

Successful applicants for the Miriam O’Connor Travelling Scholarship must be actively involved in the education of local colleagues; midwifery or medical depending on the setting.

Provide details

PART B:Details of the Proposed Presentation of Scientific Paper

Summary of Scientific Paper to be Presented

Details of Scientific Meetingat which Paper to be Presented

Name of Meeting
Organising Body
Location
Dates

section 3 – responses to assessment criteria

Evidence of Esteem in Career

Please provide any details of awards, recognition, or esteem in your career so far.

AwardInstitution / Awarding BodyDate of Award

Relevance of Proposed Activity to Conditions of Scholarship

Please outline the ways in which your proposed activity satisfies the conditions of the award(s) for which you have applied.

Significance of Award for Career

Please outline the ways in which the scholarship/fellowship would make a significant difference to your career (500 words maximum).

Opportunity for Further Learning

Please explain how the proposed activity will enhance your learning (500 words maximum).

Level of Support

Please outline the nature of the support which will be provided by the proposed institution or meeting organising committee (evidence of placement/acceptance of presentation, financial/supervisory support) (500 words maximum).

Confirmation of the Study Visit Placement/Acceptance of Presentation

This application must be accompanied by a letter confirming the study visit placement or confirmation of acceptance of the proposed presentation by the meeting organisers.

Name of Supervisor/Organiser of the Placement/Representative of Meeting Organising Committee

Letter attached

Declaration

I declare that the information supplied by me is complete, true and correct in every particular.

Signature of Applicant*
Date

Closing Date for Applications: 30 June 2018

Applications mustbe submittedto the RANZCOG Foundation via email to:

Please note:Email submission of applications is required in both Word and PDF formats.Please ensure that this page, with signatures, is submitted with your application.

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