<p> VISITING PROFESSOR SITE APPLICATION 2018 ADELE D. HOFMANN VISITING PROFESSOR IN ADOLESCENT MEDICINE and HEALTH</p><p>2018 Visiting Professor: Leslie Walker-Harding, MD, FAAP, FSAHM</p><p>Application Deadline: July 7, 2017</p><p>I. General Information </p><p>A. Name of program or organization applying for visiting professorship: ______</p><p>______</p><p>______</p><p>B. Address: ______</p><p>______</p><p>______</p><p>C. Individual to be contacted: ______</p><p>Telephone: (______) ______- ______</p><p>E-Mail Address: ______</p><p>D. Alternate individual to be contacted: ______</p><p>Telephone: (______) ______- ______</p><p>E-Mail Address: ______</p><p>II. Proposal for Visit: </p><p>A. Desired Dates for Visit: ______</p><p>Second Choice: ______</p><p>Third Choice: ______</p><p>0a5fafaf6e7c35509b17dd4bbb68dd6b.doc Page 1 of 3 B. Topics you would like to have addressed: ______</p><p>______</p><p>______</p><p>______</p><p>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.</p><p>ACTIVITY COMPOSITION OF AUDIENCE</p><p>DAY ONE</p><p>DAY TWO</p><p>DAY THREE</p><p>Other Ideas for Utilization: ______</p><p>______0a5fafaf6e7c35509b17dd4bbb68dd6b.doc Page 2 of 3 ______</p><p>D. Please enclose a letter from your organization stating its willingness to be involved in the visit. </p><p>III. Additional Information</p><p>Please share any other information you feel would help us make this decision: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>IV. Submit application</p><p>Please send completed application to: </p><p>Society for Adolescent Health & Medicine 1 Parkview Plaza, Suite 800 Oakbrook Terrace, IL 60181</p><p>Or fax it to +1.847.686.2251, Attn: Caitlyn Gibson You can also submit your completed application to [email protected]</p><p>1. The Awards Committee will make its selection in August 2017. </p><p>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. </p><p>3. Once the selection process is completed, the actual visit should be coordinated with the recipient program and Dr. Walker-Harding directly.</p><p>4. The host site awarded the professorship agrees to assume responsibility for travel expenses that exceed $1,500.</p><p>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 </p><p>0a5fafaf6e7c35509b17dd4bbb68dd6b.doc Page 3 of 3</p>