I-ACT for Children Educational Grant Application

First Name

Last Name

Phone Number

Street Address

City

State

Zip Code

Institution Information

Name of Institution

First Name of I-ACT Point of Contact

Last Name of I-ACT Point of Contact

Point of Contact's Email Address

Point of Contact's Phone Number

Additional Information

Position and Title

How many years in pediatric research?

Conference/Course Information

Name of Conference/Course

Start Date

Must start and end within calendar year 2024.

End Date

Is this an online event?

YesNo

Location City

Location State

Hotel Name (if applicable)

Anticipated (estimated) cost (include conference/course registration fee, airfare, hotel, meals, ground transportation, books/study guides):

Personal Statement

Please include a written Personal Statement.(500 words maximum)

Statement should describe your qualifications and accomplishments, including examples of your personal support of pediatric clinical research and commitment to your institution’s efforts to advocate for children’s unmet medical needs.
Statement should also explain how the selected educational program relates to your work in pediatric research, how it will benefit you and your home institution, and how it advances the I-ACT for Children mission to serve the pediatric community and improve health outcomes in children.

Is there a financial need that should be considered upon reviewing this application?

Yes

Optional Statement of Financial Need
If so, please describe. (150 words maximum)

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