American Society of Pediatric Otolaryngology Membership Application

ASPO's Pediatric ENT Rotation Program for Minority Medical Students
The ASPO Pediatric ENT Rotation Program for Minority Medical Students travel grants are intended to provide additional exposure to the field of Pediatric Otolaryngology. The mini-mentorship program is a 5-day observational experience at a regional tertiary Children’s Hospital. Awards of up to $750 will be made to the medical student awardee. This program is funded by ASPO. Arrangements for the 5 days out of your medical school schedule will need to be made with the Head of Student Affairs at the Applicant School. Anita Jeyakumar, MD MS FACS FAAP ajeyakumar@mercy.com; will coordinate the arrangements between the awardee and the host program. A maximum of 6 recipients will be awarded the travel grant per year.

Application materials required:

▪ Completed application (see below).

▪ A letter of support from your institution.

The application deadline is May 15 at 5:00 pm (EST). Decisions on funding will generally be made within four weeks of the application deadline.
Name:*

First NameLast Name
Email:*
Phone Number:*

Area CodePhone Number
Medical School:*
Year in Medical School:*
Director of Student Affairs:*
Mailing Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
One paragraph explaining your desire for exposure to pediatric otolaryngology (250 words max):*

0/250
Letter of Support from your Institution:*

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We look forward to reviewing your application. If you have any questions please contact Liz O'Keefe at aspo@facs.org or 312-202-5005.
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ASPO's Pediatric ENT Rotation Program for Minority Medical Students