Resident and Fellow Application Form

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Name (Required.)

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Degree (Required.)

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Specialty (Required.)

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Phone Number (Required.)

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Please share your personal email so that we may keep in touch with you after your Residency or Fellowship is complete.* (Required.)

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Email (Required.)

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Are you applying as a Resident or Fellow? (Required.)

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What year are you in your program? (Required.)

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Organization/Institution (Required.)

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Position

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Address (Required.)

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Phone (Required.)

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WAFIB requires the submission of a signed letter (on letterhead) from your fellowship program director confirming your status as a current fellow in February 2027. (Required.)

Before completing your application, please read and agree to the terms below.

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I have read the scholarship terms and agree that if I am awarded a scholarship, I will attend the required sessions in full and complete sign-ins at designated sessions. I understand that my scholarship will be at risk of forfeit should I miss required sessions during the conference.* (Required.)

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I have read the scholarship terms and agree that if I am awarded a scholarship I will submit my travel itinerary including flight information as soon as I have confirmed my availability to attend the conference or by the published deadline. I understand that my scholarship will be at risk of forfeit should I fail to submit this information.* (Required.)

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I have read the scholarship terms and agree that if I am awarded a scholarship I will complete the required post-conference survey by the published deadline. I understand that my scholarship will be at risk of forfeit should I fail to complete this survey.* (Required.)

The activity honorarium for fellows is subsidized by educational grants from Industry sponsors.
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