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ATS Awards / Scholarships

HomeAttendeesATS Awards / Scholarships ▶ Pediatric Resident Development Scholarship Program
Pediatric Resident Development Scholarship Program

PRDS

DEADLINE – March 1, 2019

2019 Pediatric Resident Development Scholarship Program

DEADLINE – March 1, 2019
APPLICANT INFORMATION:
First Name *

Middle Name

Last Name *

Credentials *

Mailing Address 1 (not P.O. Box) *

Mailing Address 2

City *

State *

Zip Code *

Tel *

E-mail *

Are you an ATS member? *
Yes   No  

If yes; please indicate your ATS Membership ID:

Are you an author on an abstract accepted for presentation at the ATS International Conference? *
Yes   No  

If yes, please enter Abstract Title

If yes, please enter Abstract Control/Tracking Number:

Are you a presenter in a programmed session at the ATS International Conference? *
Yes   No  

Do you have additional external or institutional support to cover the expenses of the ATS IC? *
Yes   No  

DIVERSITY AND INCLUSION
The ATS is committed to fostering diversity and inclusion across all its activities and events. Please consider answering the following optional questions:

What is your gender?
Female
Male
Non-binary/ third gender
Prefer to self-describe
Respectfully decline to answer

If prefer to self-describe is selected, please specify:

Please indicate with which of the following groups you identify (check all that apply):
Non-U.S. Citizen and Non-Permanent Resident
American Indian or Alaska Native
Asian
Black or African-American
Hispanic, Latino, or of Spanish Origin
Lesbian, Gay, Bisexual, Transgender, or Questioning
Native Hawaiian or Other Pacific Islander
White
Other
Respectfully decline to answer

PERSONAL STATEMENT:
Please include a one-page maximum Personal Statement indicating why you, the applicant, are interested in entering a career in pediatric pulmonary and/or critical care medicine and in attending the ATS International Conference.

My Personal Statement *

RESIDENCY PROGRAM INFORMATION:
Program Type: *
Pediatrics
Internal Medicine-Pediatrics

Residency program name: *

Current level: *

Completion Date: (MM/DD/YY) *

RESIDENCY DIRECTOR INFORMATION:
Director First Name *

Director Middle Name

Director Last Name *

Director Credentials *

Director Phone *

Director Email *

SPONSORING ATS MEMBER INFORMATION:






Please upload a one-page maximum letter of support from a sponsoring ATS member indicating whether he or she is willing to serve as a mentor and guide to the applicant at the International Conference. The sponsoring ATS member is asked to identify another ATS member who can serve this function, if he or she cannot fulfill this responsibility. *

APPLICANT'S SIGNATURE AND ATTESTATION:
By my electronic or physical signature, I attest that the information I have provided here is accurate, and that I agree to the terms of the ATS Resident Development Scholarship Program, including attending the ATS International Conference from at least Sunday, May 19 through Tuesday, May 21, 2019, completing a survey following the ATS International Conference and keeping my contact information with the ATS current, regardless of my membership status. I further allow the ATS to contact me to obtain additional information regarding the progress of my career for a minimum of five years following receipt of the ATS Pediatric Resident Development Scholarship.

Applicant's Signature *

Date *

The ATS Pediatric Resident Development Scholarship program is developed, organized and sponsored by the ATS Pediatric Division Directors group.