GCEP DEI Scholarship Application

The Equity, Diversity and Inclusion Committee is pleased to present the following scholarship application to increase diversity in our EP pipeline by supporting medical students in their pursuit of away rotations to Georgia emergency medicine residency programs.

Question Title

* 1. CONTACT INFORMATION

Name *

Medical School *

Address *

Address 2

City/Town *

State/Province *

ZIP/Postal Code *

Country *

Email Address *

Phone Number *

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* 2. Current Medical School Year

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* 3. Please tell us why you are seeking this scholarship (please limit your answer to 250 words or less)

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* 4. If you had $1000 to spend on something that had to do the most good for the most people, what would you spend it on? (please limit your answer to 500 words or less)

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* 5. Do you already have your away rotation confirmed?

Yes

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* 6. If the answer to the question above is YES, please upload confirmation/approval of the rotation.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 7. If the answer to question #4 is NO, then please tell us where you are in the planning stage of your rotation.

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* 8. Please upload your CV

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 9. Please upload a letter of good standing from your department of academic affairs.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 10. Please provide the following link to a member of your medical school faculty to send us a letter of recommendation:

https://www.dropbox.com/request/Vzmhj9VRT95osF2AJsUf

Additionally, please choose an option below:

I waive my right to review my letter of recommendation

I DO NOT waive my right to review my letter of recommendation

GCEP DEI Scholarship Application

Question Title

* 1. CONTACT INFORMATION

Question Title

* 2. Current Medical School Year

Question Title

* 3. Please tell us why you are seeking this scholarship (please limit your answer to 250 words or less)

Question Title

* 4. If you had $1000 to spend on something that had to do the most good for the most people, what would you spend it on? (please limit your answer to 500 words or less)

Question Title

* 5. Do you already have your away rotation confirmed?

Question Title

* 6. If the answer to the question above is YES, please upload confirmation/approval of the rotation.

Question Title

* 7. If the answer to question #4 is NO, then please tell us where you are in the planning stage of your rotation.

Question Title

* 8. Please upload your CV

Question Title

* 9. Please upload a letter of good standing from your department of academic affairs.

Question Title

* 10. Please provide the following link to a member of your medical school faculty to send us a letter of recommendation: https://www.dropbox.com/request/Vzmhj9VRT95osF2AJsUfAdditionally, please choose an option below:

* 10. Please provide the following link to a member of your medical school faculty to send us a letter of recommendation:

https://www.dropbox.com/request/Vzmhj9VRT95osF2AJsUf

Additionally, please choose an option below: