Rural Medical Student Award Application Form

Consent to Collect, Use and Disclose Personal Information

The terms of this consent agreement govern the collection, use and disclosure of your personal information which you submit to the Alberta Rural Physicians Action Plan, operating as Alberta's Rural Health Professions Action Plan ("RhPAP").

The Purpose of Collection, Use and Disclosure

RhPAP may collect, use and disclose your personal information for the purposes of providing and administering the Rural Medical School Award Program, including (without limitation):

1. Determining your eligibility for the Rural Medical School Awards;


2. Selecting Rural Medical School Award recipients based on evaluation criteria; and


3. Evaluating the Rural Medical School Awards Program.

Personal Information Subject to Consent

Your personal information that will be collected, used, and disclosed by RhPAP for the purposes of providing and administering the Rural Medical School Awards Program includes:

1. Demographic information, including name, mailing address, email, and phone number, citizenship status, and preferred pronoun;


2. Alberta residency history;


3. Medical education background;


4. Volunteer experience; and


5. Career reflections and CV

Withdrawal of Consent

You may withdraw or vary the terms of your consent in writing or electronically at any time. However, RhPAP may be unable to process your application under the Rural Medical School Award Program in the event that you withdraw or vary the terms of your consent. RhPAP reserves the right to refuse to process your application in such an event.