General Information

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* Email Address

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* Name, Affiliation and contact information of applicant.

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* Current designation and department. 

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* Are you a current IPTA member? (You need to be a current IPTA member in good standing to be eligible to apply. Please go to https://tts.org/ipta-members-area/ipta-join to become an IPTA member or to pay your dues. Your application will not be valid unless you are an IPTA member or have submitted an application to join IPTA)

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* Do you currently reside in a low income or low middle income country as defined by this list https://tts.org/member-area/member (see list of emerging economy nations). If no, your application is invalid. 

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* Are you within 10 years of your most recent post-graduate training course?. If no, your application is invalid.

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* Are you or is your institution currently signed up to the Declaration of Istanbul? (You or your institution needs to be signed up to the Declaration of Istanbul Custodians Group to be eligible to apply. Please go to http://declarationofistanbul.org/ to sign up. Your application will not be valid unless your institution is signed up to the DICG or has submitted an application to join the DICG)

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* Do you have a mentor or host centre in mind for a proposed partnership?

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* If Yes: add name, affiliation, designation and contact information of proposed mentor.

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* If No: please list up to 3 areas of expertise you would like to acquire from a mentor. IPTA can match you with an appropriate mentor. 

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* Applicant's Past Experience in Pediatric Transplant (250 words). Please describe your training, work experience and current role in pediatric transplant.

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Describe the challenges you currently experience while providing pediatric transplant services (150 words)

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* In your opinion, how would winning an Outreach Fellowship experience help overcome these challenges? (150 words)

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* State your goals and 1-2 specific objectives you aim to achieve during a 3-6 month fellowship. (250 words)

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* Please attach a budget proposal for the use of the fellowship funds with justifications for each listed expenditure. Ensure to provide details on how your home institution intends to support your fellowship experience (eg funds for travel, housing etc), if appropriate. 

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* Describe how achieving your goals will translate to implement improvement in pediatric transplantation in your home centre/ region (250 words)

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* TO BE COMPLETED BY MENTOR LIAISON: Describe how you/ your centre would support and mentor the applicant achieve their goals described above (300 words).

2. Describe how you/ your centre would support the applicant in learning skills that will translate to improved transplant services in their home country (eg hands on experience)

3. State how much time the applicant will spend with the liaison per week.

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