Scholarship Application for Travel

Please fill out the following form to apply for scholarship funds to help out with travel for dental school enrichment programs, such as the CDCA assisting and conferences/research meetings. If you have any questions, contact Emily Katz (SGA Executive Treasurer).

Name*
LECOM Email*
Enter Email Confirm Email
Application for:*
- CDCA Assisting
- Dental Conference
Name of Conference*
Location of Conference*
Start Date*
End Date*

Expenses List*

Please include an itemized list below of expected expenses (flights, hotel, conference fee). Place items on the left and corresponding cost on the right.

Item	Cost

Total Cost*
Please provide the total expected cost for your trip.
Conference Topics*
Please describe the topics to be covered or focus of the conference you plan to attend.
Educational Benefit:*
Please describe the benefit this conference will bring to your personal education.
Benefit for LECOM SDM:*
Please describe the benefit this conference will bring to the school as a whole (for research, clubs, information shared, etc):

Additional Funding*

Please list any additional funding below.

Organization/Individual Providing Funding	Amount of Funding

Funds Entitlement:*
- I understand that I am not entitled to any certain amount of money - any money to be allocated is given at the discretion of the SGA Executive Board.
Allocation of Funds:*
- I understand that I must use the allocated money appropriately and as specified in my above itemization.
Conduct and Presentation:*
- I understand I must represent L|E|C|O|M to the best of my ability and that I must present to my peers the gathered information/experiences within the academic year.
Funds Disbursement Procedure:*
- I understand that I will not receive funds until I have fulfilled all requirements (receipts, presentation, no conduct violations).