The Medical Mission
Travel Stipend Application

Thank you for your interest Medical Mission Hall of Fame. The Hall of Fame offers travel stipends through its Internatinal Health Mission (IHM) program. All public health personnel including students (e.g. doctors, nurses, dentists, public health professionals, etc.) are eligible to apply for assistance for medical missions in the form of a stpend. Once a compltere application is submitted, based on availability and the quality of your narratvie, the IHM committee will informa you of their decidion. Stipends will be disbursed after completion of your mission trip.

Please answer the following questions as completely and specifically as possible.

Participant Information:  
Name
Address
City
State
Postal Code
Email Address
Primary Phone
Work/Second Phone
Academic Institution
   
Why do you want to participate in a medical mission?
What do you hope to gain as a person from your participation?
How do you think participation in a medical mission will help your professional development?
What impact do you believe you will have on those you help on your mission trip?
What additional information would you like to provide to assist the committee in making a positive decision on your behalf?
   
Mission Information:  
Mission Leader
Mission Country
Mission Departure Date
Mission End Date
   
Expenses:  
Air Fare
Surface Transportation
Food & Lodging
Other
   
Has this trip been approved by your academic institution?