Rural Medical Student Award Application Form

Disclaimer: We encourage all full-time medical students in any year of medical school to apply.

1 Personal Information

2 Career Reflections

3 Declaration

Personal Information
Name*
First Last
Address
Street Address Address Line 2 City Province Postal Code
Phone
Email*
Citizenship
Have you lived in Alberta all your life?
How long have you lived in Alberta?
What rural community or communities do/did you live in?
Preferred Pronoun
Birthdate
Please use dd/mm/yyyy format
Date Format: DD slash MM slash YYYY
Educational Information
University
What year of medical school are you in?
Full-Time Medical Student Declaration
I am a full-time medical student.
Graduation Date:
Please use dd/mm/yyyy format
Date Format: DD slash MM slash YYYY
Have you been a volunteer in your community?
Describe your volunteer work.
Are you a member of the Rural Medicine Interest Group (RMIG) at your university?
Residence
What do you consider your home community?
List Alberta residences (including approximate time frames)

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Career Reflections
Answer the following questions thoroughly. Your answers will strongly influence the success of your application.
Describe your (short- and long-term) career plans and how they may result in you practising in a rural community.
Describe in detail any previous contact you may have had with a rural physician that may have contributed to your decision to practise medicine in a rural community.
What experiences have you acquired that will assist you in obtaining employment in medicine in a rural community (e.g. volunteer work, previous jobs)? You may include a resume.
Attach resume (optional)
Accepted file types: pdf, doc, docx.
How can you demonstrate that you will live and work in a rural community?
Is there any other information you would like to share with the selection committee.
Please provide the name and contact information of a rural physician (preferably in your community) who can attest to your interest in rural medicine.

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Declaration
The personal information requested on this form is collected for the purpose of administering and processing payments to students. Student remarks may also be used for promotional purposes. If you have any questions about the collection, use, or disposal of the information requested, please contact: Collette Featherstone, Rural Health Professions Action Plan Suite 416, 9707 - 110 Street NW Edmonton, AB T5K 2L9 Phone 780-995-2145 Fax: 780-423-9917
Declaration*
I declare that the information given on this application is true and complete and I understand it is subject to audit. If I make a false or misleading statement in this application or fail to disclose information as requested by the RhPAP, I may be denied financial assistance and/or required to immediately repay all financial assistance received.
Yes
SIN Consent*
If I am a successful recipient, I consent to provide my Social Insurance Number to RhPAP for tax purposes
Yes
Statistical Analysis*
I consent to the use of the information contained in this application by RhPAP for the purposes of statistical analysis and program evaluation
Yes
Publicity Release*
I consent to the public release of my contact, residency, and educational information if I receive an award.
Yes
Newsletter Signup
I would like to keep up to date with RhPAP and subscribe to the monthly RhPAP Review enewsletter
Yes

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Personal Information