Pediatric Resident Development Scholarship Program

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2021 Pediatric Resident Development Scholarship Program

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:
Did you submit an abstract for 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
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
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:
Sponsor First Name *
Sponsor Middle Name
Sponsor Last Name *
Sponsor Credentials *
Tel *
Email *
Please attach 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 Pediatric Resident Development Scholarship Program, including attending the ATS International Conference from at least Sunday, May 16 through Tuesday, May 18, 2021, 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.

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

Applicant's Signature *
Date *