American Medical Student Association

I. CHAPTER NAME *

Select your medical, premedical or international chapter. MEDICAL -Albany Medical College MEDICAL -Albert Einstein COM of Yeshiva University MEDICAL -Alpert Medical School of Brown University MEDICAL -Arizona COM MEDICAL -AT Still University SOM in Arizona MEDICAL -Baylor COM MEDICAL -Boston University SOM MEDICAL -Brody SOM at East Carolina University MEDICAL -Case Western Reserve University SOM MEDICAL -Columbia University College of Physicians & Surgeons MEDICAL -Creighton University SOM MEDICAL -CUNY The Sophie Davis School of Biomedical Education MEDICAL -Dartmouth Medical School MEDICAL -David Geffen SOM at UCLA MEDICAL -Des Moines University COM MEDICAL -Drexel University COM MEDICAL -Duke University SOM MEDICAL -East Tennessee State University Quillen COM MEDICAL -Eastern Virginia Medical School MEDICAL -Edward Via Virginia COM MEDICAL -Emory University SOM MEDICAL -Florida State University COM MEDICAL -George Washington University SOM & Health Sciences MEDICAL -Georgetown University Medical Center SOM MEDICAL -Harvard Medical School MEDICAL -Howard University COM MEDICAL -Indiana University SOM MEDICAL -Jefferson Medical College MEDICAL -Johns Hopkins SOM MEDICAL -Kansas City University of Medicine & Biosciences COM MEDICAL -Keck SOM of University of Southern California MEDICAL -Kirksville COM MEDICAL -Lake Erie COM MEDICAL -Lincoln Memorial University-DeBusk COM MEDICAL -Loma Linda University SOM MEDICAL -Louisiana State University HSC SOM Shreveport MEDICAL -Louisiana State University SOM in New Orleans MEDICAL -Loyola University Chicago Stritch SOM MEDICAL -Marshall University Joan C Edwards SOM MEDICAL -Mayo Medical School MEDICAL -McGill FOM MEDICAL -McMaster University Michael G DeGroote SOM MEDICAL -Medical College of Georgia SOM MEDICAL -Medical College of Wisconsin MEDICAL -Medical University of South Carolina COM MEDICAL -Meharry Medical College SOM MEDICAL -Memorial University of Newfoundland FOM MEDICAL -Mercer University SOM MEDICAL -Michigan State University CHM MEDICAL -Michigan State University COM MEDICAL -Midwestern University's Chicago COM MEDICAL -Morehouse SOM MEDICAL -Mount Sinai SOM MEDICAL -New York COM of New York Institute of Technology MEDICAL -New York Medical College MEDICAL -New York University SOM MEDICAL -Northeastern Ohio Universities COM and Pharmacy MEDICAL -Northwestern University Feinberg SOM MEDICAL -Nova Southeastern University COM MEDICAL -Ohio State University COM MEDICAL -Ohio University COM MEDICAL -Oklahoma State University Center for Health Sciences COM MEDICAL -Oregon Health & Science University SOM MEDICAL -PCOM* - Georgia Campus MEDICAL -Penn State COM MEDICAL -Philadelphia COM MEDICAL -Pikeville College SOM MEDICAL -Ponce SOM MEDICAL -Rocky Vista University COM MEDICAL -Rosalind Franklin University of Medicine & Science MEDICAL -Rush Medical College Rush University Medical Center MEDICAL -Saint Louis University SOM MEDICAL -San Juan Batista SOM MEDICAL -Sanford SOM of University of South Dakota MEDICAL -Southern Illinois University SOM MEDICAL -Stanford SOM MEDICAL -Stony Brook University Medical Center SOM MEDICAL -SUNY Downstate Medical Center COM MEDICAL -SUNY Upstate Medical University COM MEDICAL -Temple University SOM MEDICAL -Texas A&M Health Science Center COM MEDICAL -Texas Tech University Health Sciences Center SOM MEDICAL -Touro COM MEDICAL -Touro University COM MEDICAL -Touro University Nevada COM MEDICAL -Tufts University SOM MEDICAL -Tulane University SOM MEDICAL -UMDNJ New Jersey Medical School MEDICAL -UMDNJ Robert Wood Johnson Medical School MEDICAL -UMDNJ Robert Wood Johnson Medical School at Camden MEDICAL -UMDNJ SOM MEDICAL -Uniformed Services UHS F. Edward Hebert SOM MEDICAL -Universidad Central del Caribe SOM MEDICAL -University at Buffalo SOM & Biomedical Sciences MEDICAL -University of Alabama SOM MEDICAL -University of Alberta FOM & Dentistry MEDICAL -University of Arizona College of Medicine - Phoenix MEDICAL -University of Arizona COM MEDICAL -University of Arkansas for Medical Sciences COM MEDICAL -University of Calgary FOM MEDICAL -University of California, Davis SOM MEDICAL -University of California, Irvine SOM MEDICAL -University of California, Riverside SOM MEDICAL -University of California, San Diego SOM MEDICAL -University of California, San Francisco SOM MEDICAL -University of Central Florida COM MEDICAL -University of Chicago Pritzker SOM MEDICAL -University of Cincinnati COM MEDICAL -University of Colorado Health Sciences Center SOM MEDICAL -University of Connecticut SOM MEDICAL -University of Florida COM MEDICAL -University of Hawaii at Manoa John A Burns SOM MEDICAL -University of Illinois COM @ Chicago MEDICAL -University of Illinois COM @ Peoria MEDICAL -University of Illinois COM @ Rockford MEDICAL -University of Illinois COM @ Urbana-Champaign MEDICAL -University of Iowa Carver COM MEDICAL -University of Kansas SOM MEDICAL -University of Kansas SOM - Wichita MEDICAL -University of Kentucky COM MEDICAL -University of Louisville Health Sciences Center SOM MEDICAL -University of Manitoba FOM MEDICAL -University of Maryland SOM MEDICAL -University of Massachusetts Medical School MEDICAL -University of Miami Miller SOM MEDICAL -University of Miami Miller SOM at FAU Boca Raton MEDICAL -University of Michigan Medical School MEDICAL -University of Minnesota Medical School - Duluth MEDICAL -University of Minnesota Medical School (Twin Cities) MEDICAL -University of Mississippi Medical Center SOM MEDICAL -University of Missouri - Kansas City SOM MEDICAL -University of Missouri SOM (Columbia) MEDICAL -University of Nebraska Medical Center COM MEDICAL -University of Nevada SOM MEDICAL -University of New England COM MEDICAL -University of New Mexico SOM MEDICAL -University of North Carolina SOM MEDICAL -University of North Dakota SOM & Health Sciences MEDICAL -University of North Texas Health Science Center Texas COM MEDICAL -University of Oklahoma COM MEDICAL -University of Oklahoma School of Community Medicine MEDICAL -University of Ottawa FOM MEDICAL -University of Pennsylvania SOM MEDICAL -University of Pittsburgh SOM MEDICAL -University of Puerto Rico SOM MEDICAL -University of Rochester Medical Center SOM & Dentistry MEDICAL -University of South Alabama COM MEDICAL -University of South Carolina SOM MEDICAL -University of South Florida COM MEDICAL -University of Tennessee Health Science Center COM MEDICAL -University of Texas Health Science Center at San Antonio SOM MEDICAL -University of Texas Medical Branch SOM MEDICAL -University of Texas Medical School at Houston MEDICAL -University of Texas Southwestern Medical School MEDICAL -University of Toledo COM MEDICAL -University of Toronto FOM MEDICAL -University of Utah SOM MEDICAL -University of Vermont COM MEDICAL -University of Virginia SOM MEDICAL -University of Washington SOM MEDICAL -University of Western Ontario Schulich SOM & Dentistry MEDICAL -University of Wisconsin SOM & Public Health MEDICAL -Vanderbilt University SOM MEDICAL -Virginia Commonwealth University SOM MEDICAL -Wake Forest University SOM MEDICAL -Washington University in St. Louis SOM MEDICAL -Wayne State University SOM MEDICAL -Weill Cornell Medical College MEDICAL -West Virginia SOM MEDICAL -West Virginia University SOM MEDICAL -Western University of Health Sciences COM of the Pacific MEDICAL -Wright State University Boonshoft SOM MEDICAL -Yale University SOM PREMED - Abilene Christian University PREMED - Albion College PREMED - American River College PREMED - American University PREMED - Arizona State University PREMED - Arizona State University at the West Campus PREMED - Arizona State University East College PREMED - Augustana College PREMED - Baldwin-Wallace College PREMED - Barnard College PREMED - Barry University PREMED - Baylor University PREMED - Benedictine University PREMED - Berea College PREMED - Berry College PREMED - Binghamton University SUNY PREMED - Boston University PREMED - Bowling Green State University PREMED - Brenau University PREMED - Brooklyn College CUNY PREMED - Brown University PREMED - Bucknell University PREMED - Butler University PREMED - Butte College PREMED - Cabrillo College PREMED - California Lutheran University PREMED - California Polytechnic State University PREMED - California State University, Bakersfield PREMED - California State University, Fresno PREMED - California State University, Fullerton PREMED - California State University, Los Angeles PREMED - California State University, Northridge PREMED - California State University, San Bernardino PREMED - Carleton College PREMED - Case Western Reserve University PREMED - Chapman University PREMED - City College of San Francisco PREMED - Claremont McKenna College PREMED - Clayton State University PREMED - Cleveland State University PREMED - College of New Jersey PREMED - College of the Holy Cross PREMED - Colorado State University PREMED - Columbia University in the City of New York PREMED - Columbus State University PREMED - Cornell University PREMED - Creighton University PREMED - Daytona State College PREMED - Drexel University PREMED - Duke University PREMED - Earlham College PREMED - East Carolina University PREMED - East Tennessee State University PREMED - Eastern University PREMED - Eckerd College PREMED - Elon University PREMED - Emory University PREMED - Florida Atlantic University PREMED - Florida Institute of Technology PREMED - Florida International University PREMED - Florida State University PREMED - Fort Hays State University PREMED - George Fox University PREMED - George Mason University PREMED - George Washington University PREMED - Georgetown University PREMED - Georgia SouthWestern State University PREMED - Georgia State University PREMED - Georgia Tech PREMED - Gulf Coast Community College PREMED - Harvard University PREMED - Haverford College PREMED - Howard University PREMED - Hunter College PREMED - Indiana University of Pennsylvania PREMED - Indiana University-Purdue University Fort Wayne PREMED - Indiana University-Purdue University Indianapolis PREMED - Ithaca College PREMED - James Madison University PREMED - Jefferson College of Health Sciences PREMED - Johns Hopkins University PREMED - Kennesaw State University PREMED - Kent State University PREMED - Knox College PREMED - La Sierra University PREMED - Lamar University PREMED - Lawrence University PREMED - Los Medanos College PREMED - Louisiana State University PREMED - Loyola University Chicago PREMED - Marquette University PREMED - Marshall University PREMED - Massachusetts College of Pharmacy PREMED - Massachusetts Institute of Technology PREMED - Miami University (Oxford) PREMED - Michigan State University PREMED - Millersville University PREMED - Mills College PREMED - Mission College PREMED - Mississipi State University PREMED - Monterey Peninsula College PREMED - Montgomery College PREMED - Morgan State University PREMED - Mt. San Antonio College PREMED - New York Institute of Technology @ Manhattan PREMED - New York University PREMED - North Dakota State University PREMED - Northeastern University PREMED - Northwestern University PREMED - Nova Southeastern University PREMED - Occidental College PREMED - Ohio State University PREMED - Ohio University PREMED - Ohlone College PREMED - Oklahoma State University-Stillwater PREMED - Our Lady of Holy Cross College PREMED - Our Lady of the Lake College PREMED - Pepperdine University PREMED - Polytechnic University PREMED - Portland State University PREMED - Princeton University PREMED - Queens University of Charlotte PREMED - Reedley College PREMED - Rice University PREMED - Rider University PREMED - Roane State Community College PREMED - Rogers State University PREMED - Rollins College PREMED - Rutgers - Camden PREMED - Rutgers - New Brunswick PREMED - Rutgers - Newark PREMED - Sacramento City College PREMED - Sacramento State PREMED - Saint Mary's College of California PREMED - Saint Xavier University PREMED - San Diego State University PREMED - San Francisco State University PREMED - San Joaquin Delta College PREMED - San Jose State University PREMED - Simmons College PREMED - Skyline College PREMED - Southern Illinois University Carbondale PREMED - Southern Oregon University PREMED - Southwestern College PREMED - Spring Hill College PREMED - St. Edward's University PREMED - Stanford University PREMED - Stephen F. Austin State University PREMED - Stony Brook University PREMED - SUNY Cortland PREMED - Syracuse University PREMED - Tarleton State University PREMED - Temple University PREMED - Tennessee State University PREMED - Texas A&M International University PREMED - Texas A&M University PREMED - Texas A&M University-Kingsville PREMED - Texas Tech University PREMED - Texas Woman's University PREMED - Trinity College PREMED - Trinity University PREMED - Tri-State University PREMED - Truman State University PREMED - Tufts University PREMED - Univ of Michigan-Dearborn PREMED - Universidad de Puerto Rico en Bayamon PREMED - Universidad de Puerto Rico En Cayey PREMED - Universidad de Puerto Rico Recinto de Rio Piedras PREMED - Universidad de Puerto Rico Recinto Universitario de Mayaguez PREMED - Universidad del Sagrado Corazon PREMED - Universidad InterAmericana De Puerto Rico PREMED - University of Alabama PREMED - University of Alabama at Birmingham PREMED - University of Alaska Anchorage PREMED - University of Alaska Fairbanks PREMED - University of Arizona PREMED - University of Arkansas Fort Smith PREMED - University of California, Berkeley PREMED - University of California, Davis PREMED - University of California, Irvine PREMED - University of California, Los Angeles PREMED - University of California, Merced PREMED - University of California, Riverside PREMED - University of California, San Diego PREMED - University of California, Santa Barbara PREMED - University of California, Santa Cruz PREMED - University of Central Arkansas PREMED - University of Central Florida PREMED - University of Chicago PREMED - University of Cincinnati PREMED - University of Colorado at Boulder PREMED - University of Colorado at Colorado Springs PREMED - University of Colorado at Denver and Health Sciences Center PREMED - University of Delaware PREMED - University of Florida PREMED - University of Georgia PREMED - University of Houston PREMED - University of Houston-Downtown PREMED - University of Illinois at Urbana-Champaign PREMED - University of Iowa PREMED - University of Judaism PREMED - University of Kentucky PREMED - University of Maryland-College Park PREMED - University of Memphis PREMED - University of Miami PREMED - University of Michigan PREMED - University of Michigan-Flint PREMED - University of Minnesota, Twin Cities PREMED - University of Mississippi PREMED - University of Missouri-Columbia PREMED - University of Missouri-Kansas City PREMED - University of Missouri-St. Louis PREMED - University of Nebraska-Lincoln PREMED - University of Nevada, Las Vegas PREMED - University of Nevada, Reno PREMED - University of New Hampshire PREMED - University of New Mexico PREMED - University of North Carolina at Chapel Hill PREMED - University of North Carolina Charlotte PREMED - University of North Carolina Wilmington PREMED - University of North Florida PREMED - University of Notre Dame PREMED - University of Pennsylvania PREMED - University of Pittsburgh PREMED - University of Puget Sound PREMED - University of Richmond PREMED - University of San Diego PREMED - University of South Dakota PREMED - University of South Florida PREMED - University of Southern California PREMED - University of Southern Mississippi PREMED - University of St. Thomas PREMED - University of Tennessee Knoxville PREMED - University of Texas at Austin PREMED - University of the Sciences in Philadelphia PREMED - University of Utah PREMED - University of Virginia PREMED - University of Washington PREMED - University of West Florida PREMED - University of West Georgia PREMED - University of Wisconsin Milwaukee PREMED - University of Wisconsin-La Crosse PREMED - University of Wisconsin-Madison PREMED - University of Wyoming PREMED - Vanderbilt University PREMED - Virginia Tech PREMED - Wagner College PREMED - Wake Forest University PREMED - Washburn University PREMED - Washington State University PREMED - Washington University in St Louis PREMED - Wayne State University PREMED - Wesleyan University PREMED - West Virginia University PREMED - Western Michigan University PREMED - Westmont College PREMED - William Jewell College PREMED - Wilmington College PREMED - Winthrop University PREMED - Youngstown State University INTL - All Saints University INTL - American International Medical University INTL - American International SOM INTL - American University of Antigua COM INTL - American University of the Caribbean SOM INTL - Ankara University FOM INTL - Ben Gurion University Medical School for International Health INTL - Central America Health Sciences University Belize Medical College INTL - Flinders University SOM INTL - Hacettepe University FOM INTL - International American University COM INTL - International University of the Health Sciences INTL - Istanbul University Cerrahpasa Medical School INTL - Kigezi International SOM INTL - King Edward Medical University INTL - Medical University of Lublin INTL - Medical University of Silesia INTL - Medical University of the Americas-Belize INTL - Medical University of the Americas-Nevis INTL - National Defense Medical Center INTL - National University of Rwanda INTL - Poznan University of Medical Sciences INTL - Ross University SOM INTL - Royal College of Surgeons in Ireland INTL - SABA University SOM INTL - Spartan Health Sciences University SOM INTL - St Matthews University SOM INTL - St. Christopher Iba Mar Diop COM INTL - St. George's University SOM INTL - St. James SOM INTL - St. Luke SOM INTL - St. Martinus University FOM INTL - Tel Aviv University Sackler FOM INTL - Trinity SOM INTL - Universidad Autónoma de Guadalajara SOM INTL - Universidad Central del Este INTL - Universidad de Monterrey INTL - Universidad Iberoamericana SOM INTL - University College Dublin SOM & Medical Sciences INTL - University of Balamand FOM & Medical Sciences INTL - University of Dublin Trinity College SOM INTL - University of Health Sciences Antigua INTL - University of Sint Eustatius SOM INTL - University of Sydney FOM INTL - University of the West Indies Faculty of Medical Sciences SOM INTL - Weill Cornell Medical College in Qatar INTL - Windsor University SOM INTL - Xavier University SOM Bonaire

II. PROJECT LEADERS

A.	Coordinator(s)'s name *
	Full Address *	Address MUST include city, state and zip
	Telephone *
	E-mail *
B.	Chapter president's name *
	Full Address *	Address MUST include city, state and zip
	Telephone *
	E-mail *
	Please ensure that you enter the correct email address for your Project Coordinator and Chapter President. Only one email address can be entered for each; applications with multiple email addresses included will be automatically rejected by the application system. An automatic email, requesting project approval, will be generated to your Chapter President once the application is submitted. A response from your Chapter President approving the project is REQUIRED for the application to be considered for funding.

III. PROJECT DESCRIPTION AND ABSTRACT

A.	Project Description. A project description of 250 words or less is required. Feel free to include any additional information that will assist in evaluating this project (include your plans for publicity). *
B.	Abstract. A project abstract of not more than 100 words is required. The abstract should be a precise summary of the entire project as presented in this application, and will be used for publicity purposes. *

IV. PROJECT DETAILS

A.	Title *
B.	Number of local chapter member participants *
C.	Number of other health professional participants *
D.	Number in target audience *
E.	Goal of Project (25 words) *
F.	Specific measurable objectives-how you will attain your goal? (50 words) *
G.	What other alternatives were considered? (25 words) *
H.	Why were they excluded? (25 words) *
I.	If applicable, which AMSA resources and/or opportunities relevant to your project have you identified and how do you plan on incoporating them into your project? *
J.	Have you identified critical milestones and points of no return, so that progress and decisions are reviewed before work proceeds? (50 words) *
K.	If things go well, when will the goal be reached? *
L.	If problems arise, when will the goal be reached? *
M.	How will you follow-up and evaluate the success of your project? (50 words) *
N.	If you feel as if your AMSA chapter is struggling, please comment on why and how this project may help develop local AMSA activity. *

V. RESOURCE REQUIREMENTS (Name any individual participants from the following)

A.	University personnel
B.	Community representatives and community/outside organizations
C.	Local AMSA chapters
D.	Other student groups
E.	Other
F.	Will participation in the project be limited to any group? If so, explain. (25 words)

VI. FINANCE AND BUDGET

A.	Has this project ever received previous AMSA Local Project Grant funding? Yes   No
B.	Has this project been done before? Yes   No If so: 1. How is this year different/improved from previous years? 2. How was the project funded in the past (please be specific--local chapter, school, outside grant, LPG)?
C.	What additional funding sources were considered for the project this year? Specifically, have you planned to obtain any resources from the following? Please enter "0" if not considered. 1. Local Chapter Contribution * $ 2. Collaborating Groups (specify) * $ 3. Other (specify) * $ 4. AMSA (amt. requesting) * $ TOTAL *  $
D.	Required precise, itemized project budget (SEE SAMPLE). Please use the chart format below. Note: AMSA will NOT fund any requests for food, travel, or speaker honorarium. * Funding Amt Requested Item Description Narrative/ Explanation Anticipated Funding Source  1. $  2. $  3. $  4. $  5. $  6. $  7. $  8. $  9. $ 10. $ 11. $ 12. $ 13. $ 14. $ 15. $ $ TOTAL BUDGET