ASE DEI Underrepresented in Medicine (URiM) Scholarship Application

Name(Required)

First Last

Email(Required)

Institution(Required)

Position:(Required)

Graduate student

Medical student

Resident

Fellow

Research fellow

Other Healthcare Professional Student

Institution Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Are you a current member of ASE?(Required)

Yes

If not, would you be interested in becoming a member of ASE?(Required)

Yes

Are you presenting at the ASE Annual Meeting?(Required)

Yes

What is the title of your presentation?(Required)

What is the format of your presentation?(Required)

Is your institution supporting you financially?(Required)

Yes

If yes, how much financial support will you receive?(Required)

Proposed Budget(Required)

If awarded this scholarship, how much financial support would you require to attend the annual meeting? Please outline a proposed budget for meeting attendance below (consider including airfare or other travel costs, hotel or other lodging costs, meeting registration, parking, etc.). Be sure to include any financial support you are expecting to receive from your institution.

Scholarship Essay 1: In what ways do you feel you would contribute to the diversity initiatives of ASE?(Required)

Scholarship Essay 2: If awarded this scholarship, how will it contribute to your professional growth and development?(Required)

Scholarship Essay 3: What ideas do you have for how ASE as a society can promote diversity, equity, and inclusion in surgery?(Required)

Letter of Support(Required)

Please include a letter of support from faculty leadership from your institution. This could be any faculty member from your institution. It is preferable that this faculty member is also a member of ASE, but this is not mandatory. This file must be a PDF document.

Accepted file types: pdf, Max. file size: 512 MB.

Applications are due January 24, 2025

ASE DEI Underrepresented in Medicine (URiM) Scholarship Application