<p> VISITING PROFESSOR SITE APPLICATION</p><p>2017 IRIS LITT VISITING PROFESSOR IN ADOLESCENT HEALTH RESEARCH:</p><p>Michael Rich, MD, MPH, FSAHM</p><p>Application Deadline: July 8, 2016</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>Email Address: ______</p><p>D. Alternate individual to be contacted: ______</p><p>Telephone: (______) ______- ______</p><p>Email Address: ______</p><p>II. Proposal for Visit: </p><p>A. Desired Dates for Visit: ______</p><p>Second Choice: ______</p><p>Third Choice: ______</p><p>0c074c744528f665e2ba62a620d54eef.docx – SAHM Page 1 of 4 B. Topics you would like to have addressed: ______</p><p>______</p><p>______</p><p>______</p><p>______</p><p>C. Proposed Itinerary for Professor (include format: rounds, lectures, informal discussions, etc.) </p><p>ACTIVITY COMPOSITION OF AUDIENCE</p><p>DAY ONE</p><p>DAY TWO</p><p>DAY THREE</p><p>0c074c744528f665e2ba62a620d54eef.docx – SAHM Page 2 of 4 Other Ideas for Utilization: </p><p>______</p><p>______</p><p>______</p><p>______</p><p>III. Additional Information</p><p>Please summarize how this visit will enhance the research capacity of your program: ______</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 and Medicine One Parkview Plaza, Suite 800 Oakbrook Terrace, IL 60181</p><p>Or fax it to +1-847-686-2251, Attn: Ryan Norton</p><p>You can also submit your completed application to [email protected] </p><p>Please note the following: </p><p>1. The Awards Committee will make its selection in July/August 2016. </p><p>2. Once the selection process is completed, the actual visit should be coordinated with the recipient program and Dr. Rich directly.</p><p>3. The host site awarded the professorship agrees to assume responsibility for travel expenses that exceed $1,500. Society for Adolescent Health and Medicine One Parkview Plaza, Suite 800 Oakbrook Terrace, IL 60181</p><p>0c074c744528f665e2ba62a620d54eef.docx – SAHM Page 3 of 4 Phone: + 1–847–686-2246; Fax: +1-847-686-2251 www.adolescenthealth.org </p><p>0c074c744528f665e2ba62a620d54eef.docx – SAHM Page 4 of 4</p>