2015 Stanford Medicine X | Ed Resident Scholarship Application

We are so excited that you are interested in applying for the Resident Scholarship to attend Stanford Medicine X | Ed, September 23-24, 2015! If you haven't yet done so, please take a moment to review information about the the conference.

Please note that this page may time-out (refresh) after a period of inactivity, causing you to lose any unsaved content. We recommend you type your application into a word processor and then cut and paste the text into the online form for submission.

Questions? Please email us at stanfordmedx@gmail.com.

Applicant Information
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Residency Program Information
Location*
Please state the location of your current residency program. Please note, applicants must be full-time residents.
Department*
Program Director Information
Name*
First Last
Email*
Phone*
General Applicant Questions
Please tell us why you would like to come to Medicine X | Ed*
Please give an example of a challenge in medical education and describe how you would address this problem:*
What do you hope to learn by attending the conference?*
Conference Attendance: I understand that if I am chosen as a scholarship recipient, I will provide a letter to the Medicine X Staff from my program director to confirm my time off and attendance.*
- Yes
- No
Consent to Contact
I agree to allow Medicine X to contact me by email about the conference. (We are a non-profit conference and may on rare occasion send information we think will be of interest to you on behalf of our partners)*
- Yes
- No
Certification of Application
I certify that the above information is true as of the date of submission.*
PLEASE ENTER YOUR INITIALS ABOVE TO CERTIFY THIS FORM.
The Medicine X | Ed Advisory Board recognizes that situations may suddenly change, and given adequate notice and reason, the Advisory Board will work with scholarship recipients to ensure recipients are able to attend the conference.
Name
This field is for validation purposes and should be left unchanged.

2015 Stanford Medicine X | Ed Resident Scholarship Application

Applicant Information

Residency Program Information

Program Director Information

General Applicant Questions

Consent to Contact

Certification of Application