Rural Access to Anesthesia Scholarship Application

Rural Access to Anesthesia Scholarship

The American Society of Anesthesiologists sponsors a scholarship for medical student and resident members introducing future physicians to rural anesthesia.
Medical student and resident members of the American Society of Anesthesiologists can apply for stipend scholarships (with Committee oversight approval, stipends range in amount up to the value of $500) to pay for travel and lodging expenses for a rural clerkship.

Eligibility

Applicants must either be a third or fourth year medical student in an approved U.S. program or residency program, and be a member of the ASA. Join now. An ASA member mentor must oversee the activities during the rotation. Check here to see if the institution you are considering is rural.
Applicant Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is this your primary address?
Are you an ASA Medical Student or Resident Member?
Please Provide your full ASA ID Number:
7 digits
Education and Training Background
Medical School(s) Names and Heads of Program(s) and Proposed Date(s) of Graduation:
Other Medical School or Scientific Training/Experiences. Please include Institution, Date and Name:
Application
Grant amount requested if application approved (Up to $500):
Are you currently receiving funding or aid from any foundation or similar organization? If yes, please provide the name and address of the organization.
Have you ever lived in a rural area?
If 'yes' please provide the City and State:
Do you have any experience working in rural healthcare anesthesia?
How likely are you to practice anesthesia in a rural location?

1

2

3

4

5

1 is Not likely, 5 is Highly Likely
Please explain why you are interested in rural anesthesia care and want to participate in an anesthesia rural location:

LESS THAN 250 WORDS0/250
If you have experience working in rural healthcare anesthesia, please provide your experiences below:
Medical Work References (if applicable). Please provide Name, Title, Affiliation, Phone Number and Email:
Anesthesia Rotation Location:
Mentor Information

Mentor must be an ASA Member
Mentor Name

First NameLast Name
Mentor Title
Mentor Affiliation
Mentor Email
example@example.com
Mentor Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Mentor Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
By checking the box below, you understand that if approved, the scholarship funds you are awarded will be used appropriately for financial assistance for the person identified in the 'applicant' section of this application. You also agree that you will complete a post rotation essay about the applicant's rural anesthesia rotation experience:
Signature
Date of Signature

MonthDayYear
Date
Should be Empty:

Rural Access to Anesthesia Scholarship

Applicant Information

Education and Training Background

Application

Mentor Information