Funding Renewal Application

Name of physician requesting funds:(Required)

First Last

Physician email address:(Required)

Name of activity/project in FEMS:(Required)

How much was the activity/project funded for last year (approximately)?(Required)

Please share any successes from last year.(Required)

Were there any challenges from last year that you would like to share?(Required)

What is the impact of this activity/project?(Required)

How much are you requesting for this year?(Required)

What activities will this fund (e.g., meetings, development of guidelines, data analysis)?(Required)

Approximately how many physicians will be participating?(Required)

Please describe how you anticipate the Health Authority being involved. Please also include the names or positions of the people being involved.(Required)

What are some intended outputs your activity/project will produce?(Required)