Application For TGWH Foundation Scholarships

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Please DO NOT submit more than once, If you need to make changes to your original submission, please send your request to practicebasededucation@uhn.ca

For any inquiries, please contact practicebasededucation@uhn.ca

General Information

First Name *

Last Name *

Phone *

Address *

City *

Province *

Postal Code *

Employee ID # *

Professional Designation *

Position/Title at UHN *

Department *

Site *

Email *

Original date of hire *

Year

Month

Day

Name of manager/director *

Manager/director email *

Resume *

Current program of Study (1 pt)

Name of Program (degree):

Name of Institution

Year of program commencement

Expected completion date

Year

Month

Day

Previous Education (not including basic education program): (maximum of 3 pts - list up to 3)

1. Year completed

1. Name of degree program

1. Name of academic institution

2. Year completed

2. Name of degree program

2. Name of academic institution

3. Year completed

3. Name of degree program

3. Name of academic institution

Certificates (list up to 3): (maximum of 3pts)

1. Certificate completed

1. Year certificate completed

2. Certificate completed

2. Year certificate completed

3. Certificate completed

3. Year certificate completed

Additional Continuing Education Attended (list up to 3): (maximum of 3 pts)

1. Continuing education attended

1. Year completed

2. Continuing education attended

2. Year completed

3. Continuing education attended

3. Year completed

Previous UHN Scholarship Information

Have you received a scholarship from UHN before *

If yes, what year

Name of scholarship

Personal Summary

Describe the impact that you have on person-centred care at UHN in your professional role (maximum of 5 pts) *

Highlight your accomplishments at UHN that are beyond your job requirements and comment on the impact these accomplishments have had on UHN services, staff and patients (maximum of 10 pts) *

Describe your professional goals both short and long term *

Biographical sketch *

Committee and Council Work at/or related to UHN: (maximum of 5 pts)

Please list up to 5 committees and/or councils and describe your participation on each (e.g. member, chair). *

Publications/Presentations within the past 5 years: (maximum of 10 pts)

Please list up to 10 publications *

Professional Associations: (maximum of 5 pts)

Please list up to 5 ACTIVE professional associations *

Other Scholarships, Awards & Honors within the past 5 years

Please list any additional scholarships, awards or honors and note the organization that has sponsored them (non-UHN). *

Personal Acknowledgements

* I will write an acknowledgement card to the donor once I am notified that I am the successful applicant.

* I commit to 12 months of full time service or equivalent to UHN:

Personal Summary (optional)