Student Scholarship Donation Form
General Fund
Student Scholarships provide conference registration and travel support for medical students from 12 states to attend
Family Medicine Midwest at minimal cost to them. For most students, a scholarship is necessary to allow them to attend
this conference and experience all family medicine in the Midwest has to offer!
Suggested guidelines for donations:
$300 = Registration and parking for 1 student
$450 = Registration + 1 nights hotel for 1 student
$550 = Registration and 2 nights for a student traveling from more than 200 miles away
Scholarship Payment Deadline is August 1, 2015
Allocate my scholarship donation to support students in the following school(s) or state(s)
____________________________________________________________________________________
If we are unable to secure commitments from your requested students, your scholarships will go to the
next available student on the waiting list.
_________ Please use this donation where there is the greatest need
$_________
TOTAL AMOUNT ENCLOSED
Contact Name
___
Institution Name: ______________________________________________________________________
Billing Address: _______________________________________________________________________
_________________________________________________________________________________________________
Telephone ____________________ Email
PAYMENT
□ Check enclosed (payable to Family Medicine Midwest Foundation)
□ Credit Card □ Discover
□ Visa
□ MasterCard □ American Express
Card #
Expiration Date
Signature ______________________________________
Sec. Code#_______________ Total: $____________________________
Return to Family Medicine Midwest * 4756 Main St. * Lisle, IL 60532 or fax to 630-559-0739 * joleary@iafp.com
*FAMILY MEDICINE MIDWEST STATES ARE: IA, IL, IN, KS, KY, MI, MN, MO, NE, ND, SD, WI
The Family Medicine Midwest Foundation is a charitable public foundation recognized by the Internal Revenue Service as a
501(c)(3) tax-exempt organization and is thereby able to receive grants and tax-deductible gifts and contributions.