EmailMe Form - HCP Professional Development Grant Application

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Name *

First Last

Work Title / Role *

Organization / Treatment Centre / Hospital *

Department *

Business Mailing Address *

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

Business Email *

Work Phone

### - ### - ####

Cell Phone

### - ### - ####

One of the three Phone fields must be completed for your application to be considered

What is the name of the conference / workshop you would like to attend? *

Which organization is hosting the conference / workshop? *

What is the date of the conference / workshop? *

DD / MM / YYYY

Please include the website of the conference / workshop here *

Is the agenda available for the conference / workshop? *

Yes

Not yet

If yes, please upload the agenda or include the direct website link.

Direct website link for agenda

Please provide the direct website link to the agenda here

Agenda upload

If the agenda is not available online, please upload the agenda here.

Are you presenting at the conference / workshop *

Yes

No

If you are speaking at the conference / workshop, will you be

Giving an oral presentation

Presenting a poster

Facilitating a workshop

Other

What are the conference / workshop and travel costs to attend this conference / workshop? *

Registration fee

Flight / Driving / Train

Hotel

Other

Please select all that apply

Please provide a breakdown of the above travel costs: *

Example:
Registration fee = $50.00
Flight costs = $150.00
Hotel costs = $100.00
Total costs = $200.00

Do you have other sources of corporate or institutional funding to attend this conference / workshop? *

Yes

No

File Upload *

Please attach a Word Document with a 300 – 500 word essay indicating how attending the event will help you in your current role and how it will help people affected by a brain tumour. Brain Tumour Foundation of Canada’s core values are: Hope, Caring, Integrity, Accountability and Collaboration – please include in your essay, how the work you do or the professional development you are seeking aligns with our core values.