CI2024 Vancouver Student Scholarship Application

CI2024 Vancouver Student Scholarship Application

ACTIVITY: CI2024 Vancouver Cochlear Implants and Other Implantable Technologies
ACI Alliance is pleased to offer a limited number of scholarships for students, residents, and fellows in hearing sciences who wish to pursue clinical practice and/or research in cochlear implantation. The scholarships awarded will provide the conference registration, a $120 stipend, and a complimentary membership to ACI Alliance until the date of the students’ program completion.

The deadline to submit a CI2024 Student Scholarship Application is January 12, 2024.
Basic Information
Student Full/Legal Name*

First NameMiddle Name/InitialLast Name
Student Email*
example@example.com
Student Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Date of Birth

MonthDayYear
Date
Gender
Ethnic Background (Check all that apply)

African AmericanAsian/Pacific IslanderAmerican IndianHispanicWhiteOtherPrefer not to answer
Disability

Academic Information
Are you currently a graduate student?*

YesNo
Institution*
Department*
What degree are you pursuing?*
Expected degree completion date

MonthDayYear
Date
Are you a post-doc?*

YesNo

What are your research interests? Tell us in which areas you are interested in the field of cochlear implantation. (100 words or less)*
Why do you wish to attend CI2024? Summarize special skills and qualifications you have acquired from education, employment, previous volunteer work, or through personal experience and how you hope the conference might add to or enhance what you have learned thus far. (100 words or less)*
Summarize your vision as to how your education will shape your contribution to cochlear implantation in the next five (5) years. (100 words or less)*
Student Poster Competition. All applicants are encouraged to submit posters and participate in the Student Poster Competition. Are you planning to submit a Poster? (Yes/No) If yes, what is the topic of your Poster?*
Agreement and Signature

By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that if I am accepted as a scholarship recipient, any false statements, omissions, or other misrepresentations made by me on this application may result in my immediate dismissal.
Signature*

Clear
ACI Alliance Policy

It is the policy of this organization to provide equal opportunities without regard to race, color, religion, national origin, gender, sexual preference, age, or disability. Thank you for completing this application form. Please email a copy of your student ID to Jessica Houk (jhouk@acialliance.org), no later than January 3, 2024.
*The Americans with Disabilities Act (ADA) defines a person with a disability as a person who has a physical or mental impairment that substantially limits one or more major life activity. This includes people who have a record of such an impairment, even if they do not currently have a disability. It also includes individuals who do not have a disability but are regarded as having a disability. The ADA also makes it unlawful to discriminate against a person based on that person’s association with a person with a disability. https://adata.org/

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CI2024 Vancouver Student Scholarship Application

Basic Information

Academic Information

Agreement and Signature

ACI Alliance Policy