Ohiyesa Fund at Dartmouth Application Form

First Name*:

Last Name*:

Mailing Address*:

Email*:

Phone*:

Year in Medical School*:

First
Second
Third
Fourth

Expected Date of Graduation*:

Name of Project You are Seeking Funding For*:

Project Dates*:

Project Location*:

Description of Proposed Project*:

Name and Title of Mentor You Are Working With in the Host Community*:

Mentor's Address*:

Mentor's Phone*:

Mentor's Email Address*:

Amount of your Request from the Ohiyesa Fund at Dartmouth*:

Please provide a detailed budget for the project*:

What other sources of funding are you applying to/receiving, and how much are those sources providing?*: