Applicant's Full Name
Date of Birth
Do you have any other funding for your research? *
(For Medical or Graduate Students) Medical or Graduate Education:
(For Active or Allied Health Professional) Current Position:
Description of Research:
Applicant must submit the following:
1. two (2) letters of reference from educators, supervisors, a current Program Director or, in the case of active physicians or allied health professionals, colleagues in the same specialty.
2. current CV
3. abstract of submitted research
4. budget of estimated expenses
5. signed Consent Form for photos/videos (see last page of Application)
Photo and Video Consent Form:
Permission is granted to ConnectMed International the right to use photos, videos and audio recordings of me or the research that is the subject of ConnectMed’s Research Scholarship Application for the purpose of marketing and publicity. Possible uses of recorded audio-visual or photographic media include but are not limited to; ConnectMed’s website (www.connectmed.org), ConnectMed’s social media accounts (such as Facebook, Instagram, Twitter and LinkedIn), ConnectMed’s quarterly newsletters and on ConnectMed’s YouTube channel.