FMEC Home

STFM Northeast
Region Meeting

Collaborative Projects

Innovations

Awards

About Us

Board Member Login

Host Committee Login

2008 STFM Regional Meeting Medical Student Scholarship Application

A scholarship includes tuition, meals and overnight accommodations. 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 Jennifer Stamper at (937) 643-3455 or by email at Jennifer.Stamper@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
Are you a member of the American Academy of Family Physicians?	yes no
For funding purposes only, are you a member of a minority grou?	yes no
Are you a member of your State's Academy of Family Physicians?	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: Phonetic spelling (mp3)