Orthopaedics and Therapy Services Medical Student Travel Funding Application
Section I
Name
Dates Away
Start Date
End Date
Project Title
Conference
Location of Conference
Presentation Type
Name of Faculty Member Approving Funding Request
Does the faculty member have funding?
Yes
No
Section II
Estimated Cost:
Fill in the fields below with numbers and decimals only (no dollar signs).
Conference Registration
Airflight
Personal Car/Mileage
Hotel
Other/taxi/Uber etc.
Total
Carpooling with?
Sharing lodging? (List name of person with whom you are sharing)
Signature
Student Signature (Type Your Full Name)
Date
Contact Information