The Hospital for Sick Children
Application for Paediatric Radiology Fellowship
Preferred Paediatric Fellowship*:
General Radiology
Neuroradiology
Interventional Radiology
Cardiac Imaging
Nuclear Medicine
PHOTO
*Please see page 4 for important information on application deadlines.
Fellowship Start Date:
January
July
Year:
Year:
Fellowship End Date:
June
December
Year:
Year:
Name
Last
First
Middle
Mailing address
Home telephone number
Permanent address
Business Telephone number
E-mail address
Canadian Citizen
Yes
Date of birth
Sex
Place of birth
If not, citizen of what country?
No
Current position:
Marital status
Languages spoken fluently:
Name of spouse
Address
If not married, name of nearest kin
Address
Radiology Certification - Are you fully qualified or certified in Diagnostic Radiology?
Yes
ABR* certified?
ABR eligible?
Neither
Not applicable/don’t know
Date certified:
Certifying body:
No
Anticipated date of certification:
Certifying body:
* American Board of Radiology
Curriculum Vitae
Current sent?  Yes  No
Institution
Dates
Degrees
Medical School
Medical School
Radiology Certification
Funding
Are you applying for a funded position or will you be arranging your own funding? (Please see page 4 for definitions of “Funded” & “Self-Funded”)
Funded by Sick Kids
Self-Funded
Source of Funding 
1 | Page
Return to: katherine.mclaren@sickkids.ca
The Hospital for Sick Children Diagnostic Imaging Fellowship Program – Rev. May 23, 2013
References
Please have each of three referees send letters of reference directly to the Fellowship Program Director at the address listed below. Letters should
not accompany this application. One of your referees should be your Radiology Residency Program Director (or equivalent individual). If your
Program Director cannot provide a reference, attach an explanation. An application is not complete until three letters of reference have been
received under separate cover by the Fellowship Program Director.
Name of referee
Address
Telephone Number
1.
2.
3.
Professional Certification
Professional Certification
(licenses, specialty certificate, etc)
Certificate
(e.g., FRCP, FRCR, general license, etc.)
Certifying body
Date registered
Details
Date
Program/degree
Date
Radiology training
Program name/location
Medical school
University
2 | Page
Return to: katherine.mclaren@sickkids.ca
The Hospital for Sick Children Diagnostic Imaging Fellowship Program – Rev. May 23, 2013
Declaration
(Must be completed by all applicants)
1.
Have you ever been convicted of a criminal offence for which a pardon has not been granted?
Yes*
No
2.
Have you ever been convicted of any other offence (for which a pardon has not been granted) that
may affect your eligibility for Ontario Educational registration (i.e. your eligibility for an Ontario
educational license)?
Yes*
No
3.
Are there charges pending for an alleged offence that may affect your eligibility for Ontario
Educational registration?
Yes*
No
4.
Have you ever been subject to a disciplinary hearing of a medical licensing authority?
Yes*
No
5.
Have you ever been denied licensure by a medical licensing authority or had such licensure
revoked or limited?
Yes*
No
6.
Have you ever been disciplined, suspended or dismissed from an undergraduate or postgraduate
educational program?
Yes*
No
7.
Has there been concern expressed regarding your undergraduate or postgraduate (including
fellowship training) ability or performance?
Yes*
No
Was any action taken because of this?
Yes*
No
What was the outcome?
* If you answered “Yes” to any of the above, please provide details:
I hereby certify that the information given on this form and attachments is true and complete. I understand that I shall be disqualified if
information is withheld or false information has been provided and that any appointment already made or in progress will be cancelled and all
credit revoked.
Date:
Signature:
Name (print):
3 | Page
Return to: katherine.mclaren@sickkids.ca
The Hospital for Sick Children Diagnostic Imaging Fellowship Program – Rev. May 23, 2013
WHERE AND WHEN TO SUBMIT YOUR COMPLETED APPLICATION AND REFERENCES:
 WE ARE ACCEPTING APPLICATIONS FOR JULY 2015 AS FOLLOWS:
FELLOWSHIP APPLICATION DEADLINES
FOR POSITIONS
POSITIONS AVAILABLE
STARTING
Jul 2015
Funded by
Sick Kids
Jul 2015
Self-Funded
Jul 2015
General
Yes
Yes
Neuroradiology
No
Yes
Interventional
No
Yes
Cardiac
No
Yes
Nuclear Medicine
No
Yes
 COMPLETE PAGES 1, 2 AND 3 AND RETURN WITH:
 Applicant’s introduction letter
 Curriculum vitae
 Photo (a passport-style photograph)
The completed application and attachments can be e-mailed to:
katherine.mclaren@sickkids.ca
APPLICATION
PROCESS OPENS
APPLICATION PROCESS
May 1, 2013
September 3, 2013
CLOSES
While e-mail is preferable,
you may mail your package to:
Katherine McLaren
Fellowship Program
Department of Diagnostic Imaging
The Hospital for Sick Children
555 University Avenue, Room 2107C
Toronto, Ontario M5G 1X8
 REFERENCE LETTERS MUST BE ADDRESSED TO:
Dr. Oscar Navarro,
Director, Fellowship Program
The Hospital for Sick Children
Department of Diagnostic Imaging
555 University Avenue
Toronto, Ontario M5G 1X8
E-mail: oscar.navarro@sickkids.ca
Fax: 416-813-7163
and must be e-mailed, faxed or mailed separately from your application package by the referee to Dr. Oscar Navarro or emailed to katherine.mclaren@sickkids.ca.
 DEFINITIONS:
Funded Position*
Our funded fellows receive a salary of $76,000 per year. The University of Toronto fellowship programs have a minimum of one-year
duration.
Self-Funded Position*
Self-funded positions are not funded by us. Candidates obtain their own source of income.
These positions are most commonly filled by candidates who are sponsored by the governments of their country of origin or by specific
institutions who pay a salary and additional costs (accommodation, meals , transportation, insurances, pension plans, etc). Occasionally,
we have candidates who can afford these expenses on their own and come privately without sponsoring. In all cases, candidates applying
for a self-funded position have to show proof of income (official government or institutional letter, bank statement, etc) to the University of
Toronto to verify that enough funding would be available for the candidate during their fellowship.
Currently the University of Toronto requires a minimum of CDN $30,000 per year for this purpose.
* Apart from the funding, there are no other differences between the funded and self-funded positions.
4 | Page
Return to: katherine.mclaren@sickkids.ca
The Hospital for Sick Children Diagnostic Imaging Fellowship Program – Rev. May 23, 2013