Student Information Student First Name Student Last Name Email MS Year - Select -MS1MS2MS3MS4 Mentor Information Mentor First Name Mentor Last Name Degree - Select -MDPhDMD/PhD Department Section (if applicable) Email Conference Information Please note that Pritzker is unable to provide funding support for transportation or lodging for conferences in the greater Chicagoland area. Conference Name Location City Location State Conference Start Date Conference End Date Dates you are attending the conference Research Information Title of Research You Are Presenting Type of Presentation Poster Oral Other If Other Names of Any Additional Pritzker Student Co-Authors Is This Related to Your SRP Research? Yes No Is This Related to Your Scholarship & Discovery Track? Yes No If Yes, What Track? Medical Education Quality and Safety Global Health Basic Science Clinical Science Social Science Do you want this research accomplishment highlighted in the quarterly "Student Accomplishments" digital article in this website's "Pritzker Pulse" section? Yes No Outline of Estimated Expenses Conference Registration Transportation Lodging A/V Printing *Please note that Pritzker can provide a maximum of $75 to help with the cost of poster printing Total Requested Have you requested/received funds for this trip from any of the sources below? Faculty Mentor and/or their department ($) Other ($) Is this the first time that you are requesting funding to present this scholarly work outside of UofC? Yes No Click submit to send for review. For additional requests please submit an additional form. Contact Kate Blythe with any questions.