Children's Healthcare of Atlanta Rural Pediatric Scholarship Application

25-26 Children's Healthcare of Atlanta Rural Pediatric Scholarship Application

"*" indicates required fields

Name*

First Last

Preferred Name*

Date of Birth*

Primary Email Address*

Alternate Email Address

Cellphone Number*

Date of Acceptance (MM/YYYY)

For recently accepted students

Expected Date of Graduation (MM/YYYY)

For enrolled medical students

MUSM Location

Current or will attend

Current Residence*

Street Address Address Line 2 City State ZIP Code

County of Residence*

How long have you lived in your current county?*

Name of High School Attended*

Town, County and State of High School Attended*

Name of College/University Attended (Undergrad)*

Town, County and State of College/University Attended (Undergrad)*

List all cities/counties, states where you have resided since birth. Include dates (MM/YYYY) of residency.*

Example: Tifton, GA (04/1992-07/2010); Athens, GA (08/2010-05/2014); Tifton, GA (05/2014-date)

What city do you consider to be your hometown?*

Do you plan to return to your hometown to practice? If not, where would you like to practice?*

Describe your rural life experiences and desire to reside in a rural Georgia county.*

What are your career plans?*

What are your thoughts on the attributes needed to become a successful rural pediatrician and the role that a pediatrician plays in a rural community?*

Describe any experiences or interest that you may have regarding rural health policy and physician leadership development.*

What attributes do you possess that make you a top candidate for the Rural Pediatric Scholarship?*