2012-13 FACULTY OF HEALTH SCIENCES
STUDY ABROAD SUPPORT FUND
APPLICATION FORM
Award Description:
The Faculty of Health Sciences Study Abroad Support Fund is a
competitive award designed to provide financial assistance to students
engaged in academic study and/or practice education placements in an
international setting. The award program is linked to the University and
Faculty’s strategic objective to increase outgoing international
opportunities for Faculty of Health Sciences students.
Value of Award:
Eligibility:


Dependent upon available funding and the number of eligible applicants
Will not exceed $500 (CDN)


Full-time students registered in the Faculty of Health Sciences
International student experiences to be supported must be recognized and
approved at the School/Program level
The student experience must be part of an academic course, a
research/research lab placement, or practice education placement

Process:






Complete the Faculty of Health Sciences Study Abroad Support Fund
application form (attached)
Award period: September 1, 2012 to August 31, 2013
School/Program Application deadline: March 8, 2013
Applications are initially reviewed and prioritized at the School/Program
level with recommendations presented to the Faculty of Health Sciences
International Committee (FHSIC) for final decisions
School/Program recommendations are forwarded to the FHSIC by March
29, 2013
FHSIC decisions on funding: April 19, 2013
Additional Information:
Dr. Darwin M. Semotiuk, Chair
FHS International Committee
Telephone Number: 519-661-3088
E-mail: semotiuk@uwo.ca
2012-13 FACULTY OF HEALTH SCIENCES
STUDY ABROAD SUPPORT FUND
APPLICATION FORM
Personal Information (Please Print)
Name: ___________________________________ Student #:
______________________
Social Insurance (SIN) #: ____________ Date of Birth : __________ Male: ___ Female: ___
(D/M/Y)
Program/School: __________________________ Current Year of Registration: ______________
Mailing Address (for reimbursement cheque): ___________________________________________
________________________________________________________________________________
Telephone Number: ___________________
E-mail Address: ________________________
Are you /have you been employed by Western? Y __ N __ UWO Employee # ________________
Supporting Documentation:
Briefly outline below:
1. The international experience for which you are requesting funding (e.g. course number,
location, placement site, etc.). ____________________________________________________
_____________________________________________________________________________
2. The length of the experience (i.e. days/weeks/months) __________________________________
3. The anticipated or actual costs incurred. ____________________________________________
_____________________________________________________________________________
4. Other funding sources applied for: _________________________________________________
______________________________________________________ Amount: _______________
5. Other funding sources confirmed or received ________________________________________
______________________________________________________ Amount: _______________
2012-13 FACULTY OF HEALTH SCIENCES
STUDY ABROAD SUPPORT FUND
APPLICATION FORM
Ambassadorial Statement:
1. Describe how you will act as an ambassador for your School, Faculty and University while
participating in this international academic study and/or practice education placement.
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
Signature: _______________________________
Date: _________________
Completed applications (hard copy preferred) should be submitted to your FHSIC
School/Program Representative:
School of Health Studies: Dr. Deborah Fitzsimmons (dfitzsi4@uwo.ca)
School of Communication Sciences & Disorders: Prof. Susan Schurr (sschurr@uwo.ca)
School of Kinesiology: Dr. Alan Salmoni (asalmoni@uwo.ca)
School of Nursing: Dr. Yolanda Babenko-Mould (ybabenko@uwo.ca)
School of Occupational Therapy: Prof. Ann Bossers (abossers@uwo.ca)
School of Physical Therapy: Prof. Ann MacPhail (amacpha3@uwo.ca)
Note: Western University is committed to protecting the privacy of personal information. The above
information will be used, maintained, disclosed and disposed of in accordance with the applicable
provincial or federal legislation.
2012-13 FACULTY OF HEALTH SCIENCES
STUDY ABROAD SUPPORT FUND
APPLICATION FORM
Students with Financial Need
In addition to the FHS Study Abroad Award, I wish to be considered for a needs-based
award as well.
Special Circumstances: In a separate letter, please outline any special or extenuating
circumstances, which must be documented, that you would like the Dean’s Office to consider as we
review your application.