Rural Scholarship Form

Geoffrey Thompson Rural / Regional Scholarship Application

Are you available to attend the ACSEP conference In Melbourne from 16-19 October 2024?

Yes

Full Name

*Email

Phone

*Post Code

(e.g. Year 1)

Which university do you attend?

Year of study

Where do you currently practice?

I have at least 12 months post-graduate medical work experience in a regional or rural (Modified Monash Model 2-7) area.

Yes

If yes, please indicate the employer and location:

I have completed at least 24 months of medical school training in a regional or rural (Modified Monash Model 2-7) area.

Yes

If yes, please indicate the university and location:

I completed at least 5 years of primary or secondary school in a regional or rural (Modified Monash Model 2-7) area.

Yes

If yes, please indicate the school and location:

Why are you interested in attending the ACSEP Annual Scientific Conference and how do you think you will benefit from attending?

Why are you interested in Sport and Exercise Medicine?

What are you most proud of, either in your professional or personal life? 

Any other comments?

*Security Check