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2010 FMEC Regional Meeting Medical Student Scholarship Application

A scholarship includes tuition, meals and overnight accommodations at the Hershey Lodge & Convention Center in Hershey, PA. Students will share a hotel room with two or three students per room. If you prefer to share a room with a particular individual, please indicate the person's name below. Please complete and return the following to the address below. A letter indicating your receipt of a scholarship will be sent after this registration form has been processed. For additional information, contact Laurence Bauer, MSW (937) 428-7866. Laurence.Bauer@fmec.net or www.fmec.net

Please complete all fields.

Student's First Name:

Student's Last Name:

Sex:

male   female

Medical School:

Current Class Level:

MSI   MSII
MSIII   MSIV

Mailing Address:

City:

State:

Zip Code:

Phone Number:

Fax Number:
(if available)

Email Address:

Hotel Accommodation:
I will need a hotel room on (select one)

Friday Only  
Friday and Saturday
Saturday only
I will not need a hotel room

I prefer to share a hotel room with
I would like to request vegetarian meals:
(deadline to request Vegetarian meals is Oct. 15th)		 yes   no

Are you a member of the American Academy of Family Physicians?

yes   no

Are you a member of your State's Academy of Family Physicians?

yes   no

For funding purposes only, are you a member of a minority group?

yes   no

May we share your mailing address with Residency Directors in the Northeast Region?

yes   no

Please enter the letters in the image below:

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Phonetic spelling (mp3) 

    

   
All medical students applying for a scholarship are required to join the FMEC at the student rate of $20.00. The FMEC is a 501C3 non-profit organization and your membership is tax deductible. Retain your PayPal receipt for your tax records. If you wish to continue with your application and join the FMEC at the student rate of $20.00, please complete the membership information below:
FMEC Member? yes   no
If you are not a member, join here (Paypal).

After you join, please use your pay pal receipt # as your member number below. This will allow you to continue with the application”.
Member Number
If you do not wish to continue with your application, please click here