Education and Research Fellowship Fund Application Form - The Association for Perioperative Practice

Personal Details

Name*

Prefix First Last

Address*

Street Address Address Line 2 City County Post Code Country

Phone*

Email*

Enter Email Confirm Email

Professional Information

Current job title and grade:*

Place of work*

Details of Research

Name of course/study day/conference/title of research*

Course date(s):*

Details of Bursary

Course fee (max one year)*

Other expenses

Total bursary requested*

Are you a member of AfPP?*

Yes
No

AfPP Membership Number

Are you a full-time student?*

Yes
No

How much financial assistance was requested from your place of work?

Requested financial assistance evidence

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

How much financial assistance was granted from your place of work?

Granted financial assistance evidence

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

How much study leave has been granted from your place of work?*

Have you applied for funding from elsewhere? Please provide further details*

Further Information

1. PATIENT: Please explain how the course/research will benefit the perioperative patient care in your workplace?*

2. SELF: How will this course/research enable you to improve your working practice?*

3. ENVIRONMENT: How do you intend the course/research to support the organisational culture of your department?*

4. DISSEMINATION: How do you intend to share the knowledge gained with your work colleagues and peers?*

You are required to enclose a 500 word (max) supporting statement demonstrating how funding would benefit you and the perioperative environment you work in. (Please expand on points 2 and 3 above).*

Please provide supporting evidence for the course/event/research

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 5 MB.

Full details of: costs (i.e. University quote or a copy of a college prospectus quoting module fees/dates), the course to be undertaken (including dates), breakdown of research proposals/costings (research applications only).

Confirmation*

I agree to abide by the criteria for general applications to AfPP and confirm that the information I have provided is true and complete.

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