HIVMA Medical Students Program

The HIV Medical Students program awards grants to medical student and mentor pairs to support a longitudinal clinical learning and/or research project and mentor relationship up to three years in length.

This form is to submit information for your application. Please also email your CV to ndanskey@hivma.org. Additionally, please ask your mentor to submit a letter of support not to exceed two pages. The deadline for all application materials is February 15.

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* 1. General Information

First Name

Middle Initials

Last Name

Email address

Institution

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* 2. Contact Information

Street Address

Address Line 2

City

State

Zip

Phone

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* 3. Year in School

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* 4. In 500 words or less, please discuss your interest in the field of HIV focusing on your project plan for the three years of the HIVMA Medical Students program. Include learning goals and activities or projects that you anticipate completing with this support and how they complement your training curriculum.

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* 5. Mentor Information

Mentor's Name

Mentor's Phone

Mentor's E-mail

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* 6. How did you learn about the HIVMA Medical Student Program?

Google or other search engine

HIVMA member

Program Director

Other (please specify)