Visiting Professor Site Application s1

VISITING PROFESSOR SITE APPLICATION 2018 ADELE D. HOFMANN VISITING PROFESSOR IN ADOLESCENT MEDICINE and HEALTH

2018 Visiting Professor: Leslie Walker-Harding, MD, FAAP, FSAHM

Application Deadline: July 7, 2017

I. General Information

A. Name of program or organization applying for visiting professorship: ______

______

B. Address: ______

______

C. Individual to be contacted: ______

Telephone: (______) ______- ______

E-Mail Address: ______

D. Alternate individual to be contacted: ______

Telephone: (______) ______- ______

E-Mail Address: ______

II. Proposal for Visit:

A. Desired Dates for Visit: ______

Second Choice: ______

Third Choice: ______

0a5fafaf6e7c35509b17dd4bbb68dd6b.doc Page 1 of 3 B. Topics you would like to have addressed: ______

______

C. Proposed Itinerary for Professor (include format: rounds, lectures, informal discussions, etc.) Please note: Applications will be evaluated based on their demonstration that the visiting professorship program will enhance the research capacity of trainees, graduate or post-graduate students, faculty, and other health professionals who serve adolescents. Programs are expected to outline a clear plan for how the visiting professor’s visit will be structured, giving appropriate attention to the purpose and goals associated with proposed activities.

ACTIVITY COMPOSITION OF AUDIENCE

DAY ONE

DAY TWO

DAY THREE

Other Ideas for Utilization: ______

______0a5fafaf6e7c35509b17dd4bbb68dd6b.doc Page 2 of 3 ______

D. Please enclose a letter from your organization stating its willingness to be involved in the visit.

III. Additional Information

Please share any other information you feel would help us make this decision: ______

______

IV. Submit application

Please send completed application to:

Society for Adolescent Health & Medicine 1 Parkview Plaza, Suite 800 Oakbrook Terrace, IL 60181

Or fax it to +1.847.686.2251, Attn: Caitlyn Gibson You can also submit your completed application to [email protected]

1. The Awards Committee will make its selection in August 2017.

2. This selection will be approved and announced by the Society for Adolescent Health and Medicine’s Board of Directors in the fall of 2017.

3. Once the selection process is completed, the actual visit should be coordinated with the recipient program and Dr. Walker-Harding directly.

4. The host site awarded the professorship agrees to assume responsibility for travel expenses that exceed $1,500.

Society for Adolescent Health and Medicine 1 Parkview Plaza, Suite 800 Oakbrook Terrace, IL 60181 Phone: +1.847.686.2246; Fax: +1.847.686.2251 [email protected] www.adolescenthealth.org

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