Ume Travel Award Request Form

UME TRAVEL AWARD REQUEST FORM

Please submit completed Travel Award Request Packet electronically to

Jennifer Hernandez at

Name: MS Year:

SECTION A: To be eligible for a travel award you must answer YES to ALL

1. Are you an ACTIVE MEDICAL student? ☐Yes ☐If No, you do not meet criteria to apply

2. Are you a Texas Resident? ☐Yes ☐If No, you do not meet criteria to apply

3. Do you have financial need? (Determined by your FASFA) ☐Yes ☐If No, you do not meet criteria to apply

4. Are you in good academic standing? (No failures in current year pending remediation or currently repeating a year) ☐Yes ☐If No, you do not meet criteria to apply

SECTION B: To be eligible for a UME Travel Award you must answer YES to at least ONE

1. Presenting research/poster at a national/regional conference ☐Yes ☐No

2. Currently hold an organizational officer position (registered with the Office of Student Life) and serving as a representative at a national meeting or conference

☐Yes ☐No If yes, Name of organization: Position:

SECTION C:

Destination: Depart Date: Return Date: Purpose for Travel:

Curriculum Activities: Does your travel require an excused absence? ☐Yes ☐No

If yes, the approved excused must be submitted with this application. ☐ Yes, my excused absence is submitted with my packet.

Travel Budget:

SPLIT COSTS: Please provide ONLY YOUR PORTION of the split costs.

The following expenses will be split: with the following student(s):

Airfare: Lodging: Other transportation (Taxi, mileage, etc.):

Meals: Registration/Fees: Other Expenses: Define Other:

*Additional Funding Received: ☐ Yes, Funding Source: Amount: ☐ No additional funding

☐ By checking this box and providing my HSC ID#, I certify I have read and understand the Undergraduate Medical Education Travel Award Guidelines. HSC ID#:

Long School of Medicine