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Awards & Grants

Don and Elizabeth Hillman International Health Grant 

Application Form

Submission deadlines:

  • Fall Grant - October 31
  • Spring Grant - April 30

Before proceeding with this application, please make sure to review the guidelines. Please have all required attachments ready. All field marked with * are mandatory.

Membership Number:
SECTION 1 - APPLICANT DATA
* Salutation:       
* First Name:  *   Last Name: 
  Address:
  City:
  Province:
  Postal Code:

  Tel:    ext.
  Fax:
  E-mail:
  Training:         Training Year: 
If fellowship or 4th year, please specify specialty: 
SECTION 2 - PROGRAM INFORMATION
Program Director's Information:
First Name:           Last Name:  
Institution:           Department: 
Address:
City:
Province:
Postal Code:
Tel:      ext.
Fax:
E-mail
SECTION 3 - ELECTIVE INFORMATION
* Place(s) of Proposed Elective:     
  Proposed Date of Elective:
  Start Date:  
  End Date:   
  Elective Supervisor:
* Salutation:  * First Name:  * Last Name:
Please answer the following questions (maximum 300 words per question):
* 1. Provide a brief overview of the elective (i.e. region, facility, work, specialty, etc)
* 2. Why have you selected this elective?
* 3. What are the three most important things you hope you will learn?
* 4. What child health problems might you encounter during your elective?
* 5. What community or country factors could impact health or health care of the children you will
       see?
* 6. What personal and professional challenges might you encounter during your elective and
       how could you manage them?
* 7. How might this elective impact your future practice as a paediatrician?
* 8. Have you had any previous experiences that have encouraged your interest in international
       health?
* 9. Upon return, how will you share your experiences with other Canadians?
* 10. List your specific objectives for this elective (maximum of five objectives)
* 11. Please attach a brief confirmation of the elective from your local elective supervisor 
         (MS Word format only).
* 12. Please attach a brief letter from your program director indicating good standing in your
         residency program and support for your upcoming elective (MS Word format only).
Note: The above attachments are required as part of the package but will not be factored into the scoring.
SECTION 4 - APPROPRIATE ELECTIVE DOCUMENTS
All applicants should have valid healthcare coverage, medical licensing, a valid visa (if required) and vaccinations/malaria prophylaxis as recommended by a travel clinic/tropical medicine specialist, prior to initiating any travel.
Have you organized the following?
* 1. Valid health care insurance?
      Yes        No
       If no, please explain
* 2. Valid passport and visa for the country/countries you will visit?
      Yes        No
       If no, please explain
* 3. All required and recommended vaccines for travel to your destination country/countries?
      Yes        No
       If no, please explain
* 4. Appropriate medical approval/licensing for practice as a trainee in the medical setting in 
       which your elective is planned?  
      Yes        No
       If no, please explain
Note: All trainees traveling overseas for electives should register with the local Canadian consulate and check local country security status prior to travel. This can be done online at: https://www.voyage.gc.ca/.
SECTION 5 - OTHER FUNDING
The following questions pertain to additional funding you have either applied for or been granted for this elective - this includes  your fellowship/residency training program or outside organizations.
1. Have you applied for or been granted funding to help support this elective?
    Yes        No
    If yes, specify organization or program and amount granted/applied for below
    Organization: 
    Amount:         $

 

 
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