Medical Professional Education Reimbursement Grant Application

The Mid-America Transplant Foundation has established an Education Grant for medical professionals in our designated service area. These grants will assist in covering costs associated with continuing education for those professionals working in critical care and trauma medicine. The Foundation is focused on supporting education training that will support the area of organ and/or tissue donation and transplantation.

APPLICANT REQUIREMENTS

Complete application form. Please submit one application per individual.
Submit seminar/class informational brochure. Training must be related to organ and/or tissue donation and transplantation.

ALL REQUIREMENTS MUST BE MET, OR APPLICATION WILL NOT BE CONSIDERED

Applications are considered on a rolling basis until all funds have been committed for the year.

When an application is approved, a check for payment will be processed and sent directly to the Applicant pending receipt of appropriate documentation that training has been completed.

Please note: Verification will be requested that the course/training was completed by the Applicant.

Hospital(Required)

Name(Required)

First Last

Area of practice(Required)

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

Referred by (if applicable)

Name of course/training and how it supports the work of organ and/or tissue donation and transplantation(Required)

Total anticipated expenses(Required)

Dates and location of training(Required)

Applicant signature(Required)

Date(Required)