2023 Global Outreach Grant & Robert K. Pedersen Global Outreach Grant
Application Form

Step 1: Review the qualifications and requirements document.

Step 2: Fill out form below and upload all required supporting materials.

Application Deadline: June 9, 2023

Applicant Information

Applicant name: *

AAPA ID #: *

Applicant status: *

Practicing PA

PA Program Faculty

PA Student

Applicant street address: *

Address line 2:

City: *

State: *

Zip code: *

E-mail address: *

Phone number: *

Fax number:

If applicant is a student, name of faculty sponsor:

PA program:

Sponsoring Organization Information

The sponsoring organization is the organization that will receive/manage grant funding if selected as a grantee. Grant funds are disbursed to this organization rather than to the individual applicant. It must be a nonprofit organization (PA program, constituent organization, or other organization with nonprofit status).

Sponsoring organization name: *

Is this the organization that will receive/manage grant funding (if awarded)? *

Yes

No

If no, please indicate the name of the organization that will receive/manage grant funds. *

Sponsoring organization status: *

PA program

Constituent organization

Nonprofit organization

Name and title of main contact at sponsoring organization: *

Sponsoring organization address: *

Address line 2:

City: *

State: *

Zip code: *

E-mail address (main contact):

Phone number:

Fax number:

Is this organization incorporated? *

Yes

No

Is this organization a nonprofit? (must be a nonprofit in order to meet eligibility criteria) *

Yes

No

Project Information

Project title: *

Brief description of project (250 word maximum): *

0/250 words

Funding requested: *

Total project budget: *

If selected as a grantee, check should be made payable to (sponsoring organization name): *

Required Documents

Attach detailed project budget. *

If project is to be conducted outside of the United States, attach document of support from host country (see item #3 under "Application Requirements" in the requirements document).

If project is to be conducted within the United States, attach letter of support from the humanitarian organization with which you will be working (see item #4 under "Application Requirements" in the requirements document).

Attach written proposal (maximum 8 pages) addressing the items/questions included in the requirements document (see item #5 under "Application Requirements" in the requirements document). * 🛈

Attestations

Please review and indicate your agreement with the following statements by checking the box next to each. *

I attest that the contents of this grant application are true and accurate. I agree that if awarded a grant, information about this project and my photograph may be published in AAPA and PA Foundation publications and news releases.

I attest that the individuals and organizations applying for this grant do not advocate, support, or engage in discrimination in the provision of health care on the basis of age, color, disability, ethnicity, gender identity or expression, national origin, union membership, political affiliation, race, size, religious affiliation, sex, sexual orientation, or socioeconomic or veteran status.

Digital Signature of Applicant: *

clear

Date: +

Sponsoring Organization Attestations
To be signed by main contact at sponsoring organization. If the individual applicant is affiliated with the sponsoring organization, form should be signed by the applicant's supervisor; if no supervisor, applicant may sign it.

View sponsoring organization attestation form

Upload signed sponsoring organization attestation form. *

Faculty Sponsor Attestations

To be completed only if applicant is a PA student.

View faculty sponsor attestation form.

Upload signed faculty sponsor attestation form (if applicable).

Additional Questions

The PA Foundation would like to know more about the individuals applying to our programs. Please provide the following information if you are comfortable doing so, or select “Prefer not to respond.” This information will not be used in the grant selection process.

Do you identify as a sexual or gender minority*? *

Yes

No

Prefer not to respond

*From the National Institutes of Health: Sexual and gender minority (SGM) populations include, but are not limited to, individuals who identify as lesbian, gay, bisexual, asexual, transgender, Two-Spirit, queer, and/or intersex. Individuals with same-sex or -gender attractions or behaviors and those with a difference in sex development are also included. These populations also encompass those who do not self-identify with one of these terms but whose sexual orientation, gender identity or expression, or reproductive development is characterized by non-binary constructs of sexual orientation, gender, and/or sex.

Race/ethnicity (select all that apply): *

Career stage: *

Thank you for completing this application!