LHHINS Application Form

Personal Details

Name*

Prefix First Middle Last Suffix

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Email*

Educational Attainment*

Job Title*

Employer*

Statement of Scholarship Purpose

Provide a statement (max. 500 words) describing what you hope to achieve with this scholarship experience and how that can benefit your professional development/education. Please include how this can also impact your workplace and the greater community.

Provide your statement of Scholarship Purpose*

Project Proposal

Provide a clear outline of the activity or project. This should include the project plan, objectives, and intended outcomes. (max. 1500 words)

Provide your project proposal here*

Submit Your Required Documents

Please use the following link to submit the following documents:

– Current CV
– A letter of support from the applicant’s supervisor, manager, clinical director or equivalent.
– Two letters of recommendation
– Required travel documents including Visa
– Required vaccination record specific to host institution/country

Submit your required documents via mission:brain’s Dropbox

Accuracy of Statement

I hereby confirm that the information provided on my application and CV/Resume is to the best of my knowledge true. I consent to this information being verified by mission:brain to contacting my school of attainment and/or employer(s) as needed.*

Agree

Disagree

Name

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