ACDS Mentoring Award Application

Thank you for your interest in applying for the ACDS Mentoring Award Grant. Please complete the below information and submit by the designated deadline to be considered for the grant. Please contact info@contactderm.org or call 414-918-9805 with any questions you might have.

* = required field

Applicant's Contact Information

First Name*:

Last Name*:

Applicant's Title* (Medical Student, Resident, Fellow, etc.):

Street/Mailing Address:

Street/Mailing Address (line 2):

City:

State/Province:

ZIP/Postal Code:

Country:

Phone* (include extension):

Fax:

Email*:

Mentoring Program Details

Proposed Mentor*:

Mentor's Email*:

Mentor's Institution*:

Area of Focus in Contact Dermatitis*:

Proposed Dates of Program*:

Location*:

Statement of Purpose

Describe the goal(s) of the proposed program and any specific project planned. Indicate how you envision this mentoring opportunity will impact your future in dermatology, specifically in helping you prepare to become an expert in the field of contact dermatitis.

Upload your statement of purpose as a PDF or Word document:

Proposed Budget

Budgeted items may include expenses related to travel to the program and research, but may not include such items as software, books, lab materials, or registration fees for meetings or travel to meetings. Total amount should be in US dollars.

Amount requested*:

Budget as PDF or MS Word file*:

Other Information

Upload letter of support from your mentor*:

Upload letter of support from your program chair (if applicable):

Upload your Curriculum Vitae*:

I certify that the statements in this application are true to the best of my knowledge. I agree that the award funds will be used only for the purpose reflected in my application. Any unused funds will be returned to the ACDS. I hereby agree to provide a written progress report and financial report to the ACDS within 90 days of the termination of my mentorship program.

ACDS Mentoring Award Application

Applicant's Contact Information

Mentoring Program Details

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