COVID-19 CMA BURSARIES APPLICATION FORM

The Canadian Medical Association (CMA) Foundation recently announced funding that would be available to assist students/residents who are facing financial difficulty due to unexpected and immediate hardships resulting from the COVID-19 pandemic. This emergency financial support program is in addition to the various Government assistance programs in relation to COVID-19 (CERB, CESB) and applicants must have exhausted any Government supports applicable to them.
Last (Family) Name:
 
First Name:
 
Student Number: B00
 
Telephone Number:
 
Dalhousie Email Address:
 
Current Address:
 
City/Town where you graduated high school from:
 
Year of Study as of January 2021:
Med 1  
Med 2  
Med 3  
Med 4  
PGY 1  
PGY 2  
PGY 3  
PGY 4  
PGY 5  
Other   
1.Do you wish to self-identify as an applicant in any of the following categories:
Indigenous Person  
Racially Visible Person  
Person with a Disability  
Person of a Minority Sexual Orientation and/or Gender Expression  
I do not wish to self-identify  
2.What is the cumulative financial impact between August 2020 to January 2021 (excluding direct loss of income) as a result of COVID 19. Please use the categories listed below and provide detailed explanations to support amounts entered.
ExpenseIncremental IncreaseExplanation
(Combined Total from August to January)
Living Needs
Unanticipated Travel
Childcare
Food
Tuition
Other:
TOTAL
 Additional comments:
3.Please provide details regarding your original financial plan to fund your education and how COVID 19 has impacted this.
 
Funding is being provided by the CMA. Do you consent to sharing this information with the CMA Foundation?
I consent  
I do not consent  
DECLARATION
  • All statements in this application are true and complete to the best of my knowledge.
  • Any misrepresentation/falsification of information may result in cancellation of my application or award. I may also be required to repay an award.
  • All information is subject to verification. Upon request, I will provide further supporting documentation.
  • I agree if awarded funds, they will be disbursed by e-transfer via my Dalhousie email address.
  • I understand summary information collected from applications in addition to funding amounts awarded will be provided to CMA Foundation. This information will not contain any identifying student details.
I agree with all the above statements   
 DATE