International Association for Hospice & Palliative Care

IAHPC Scholarship Program Application

Applicant must be a current IAHPC member. If you need to join or renew your membership, click here.

Applicant Information

Given Name of Applicant *

Surname Name of Applicant *

IAHPC Membership Number *

To locate your IAHPC number click here.

What name would you like displayed publicly?

Address *

City *

State/Province

ZIP/Postal code

Country *

Email *

Salutation *

Are you an MD? *

Specialty *

Current position/title *

Institution *

Number of years since graduation *

Number of years working in palliative Care *

Proportion of your current working time devoted to PC *

Please attach a recent photograph of yourself (headshot only) to accompany the grant (PDF or JPG formats only / 2 MB of max file size). This photo will be attached to your IAHPC membership profile *

By submitting a photo I confirm that I have read the authorization, release, and agreement, prior to its execution, and confirm that I am fully familiar with its contents.

Please upload a copy of you recent CV (2 MB of max file size) *
Use this Word document to create your CV. Insert your relevant information as instructed in the CV Template, save the Word document and upload the document into the scholarship application.

Please upload a letter from your direct supervisor written in your institution letterhead (PDF or JPG formats only / 2 MB of max file size) stating that if you are granted this scholarship, the institution gives you the authorization to participate in this activity. *

Is your institution an IAHPC active member?
Your institution must be listed on the IAHPC members’ list located here.

Yes

Activities

Name of Event / Meeting / Activity you wish to participate in *

Modality *

Event City *

Event Country *

Event date from *

mm-dd-yyyy

Event date to *

mm-dd-yyyy

Provide the link to the event’s website

I confirm that I understand the official language of the congress/educational event I am applying to. *

I confirm that I have permission from my supervisor to participate in this virtual conference. *

I confirm that I am able to attend this virtual event regardless of the hour difference between my time zone and the time zone of the event. *

Using Speedtest please state your current Wi-Fi download and upload capacity.

Download speed *

Upload speed *

Name of sponsoring/host organization/institution (the name of the organization / institution who is producing the Event / Meeting / Activity you wish to participate in) *

Event’s Contact Person *

Event’s Contact Person Phone

Event’s Contact Person Email *

Check if you will be presenting a poster or oral presentation (the IAHPC will contact the Event Contact Person to verify your abstract has been accepted to present a poster or oral presentation)

Name of poster/oral presentation *

IAHPC believes that palliative care workers, in addition to being health care providers, may also be effective agents of change in their own countries and settings.

The goal of the IAHPC Scholarship Program is to provide financial assistance to palliative care professionals to participate events that will enable them to improve palliative care in their settings. These should ultimately lead to better and adequate policies and/or institutional norms, increased access to palliative care as well as access to essential medicines for pain relief and palliative care.

In the space below describe your anticipated outcomes from participating in this event. Be specific on how you will use your new knowledge and skills to improve palliative care one or more of the categories below in your country, and/or municipality, and/or institution:

Education
Access to essential medicines
Care provision
Policies

Expenses in USD

Registration Costs *
Registration fee must match the registration fee listed on the event’s website

Travel Expenses (airfare, ground transportation, etc.)*
The IAHPC team will use online travel websites such as Expedia and Kayak to determine amount of airfare provided

List other sources of funding for your trip (complete all that apply):

Own founds

Other donor(s) amount

Comments