Student/Organization Request for Funds Form - College of Medicine

Name*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email*
Check One:*
- Class of 2026 (Incoming Freshman 2022)
- Class of 2025 (Current M1)
- Class of 2024 (Current M2)
- Class of 2023 (Current M3)
- Class of 2022 (Current M4)
If applying as a student organization, list names of additional students:
If you have funding from other sources, list the organization name and amount.
1)
Amount
2)
Amount
3)
Amount
4)
Amount
Name of Event:*
Location of Event:*
Total Estimated Cost for Event:*
Student/Organization Contribution:*
Amount requested from UAMS Parents Club:*
Itemize estimated cost included in "Total Cost"
Conference fees:*
Travel: Driving Vehicle*
Air Fair:*
Food:*
Lodging per night:*
Total Lodging:*
Attendee's Participation at Event (i.e. attending only, presenting a Paper/Poster, speaking):*
Describe the Expected Positive Outcome of the Event for UAMS and/or UAMS Students:*
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