Fellowship Application Form

DFL Fellowship Application

Step 1 of 7

Applicant Details
Name*
First Last
Date of Birth*
Nationality*
Address*
Street Address City State / Province / Region Country
Email*
Phone Number*

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Experience
Current Position:
Position
Organization
Address
Date Started

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Education
University/ College Please include details of any Universities/ Colleges you have previously attended, starting with the most recent.
University/College #1
University/College
City, Country
Program of Study
Degree
Cumulative GPA
Date of Completion
University/College #2
University/College
City, Country
Program of Study
Degree
Cumulative GPA
Date of Completion
University/College #3
University/College
City, Country
Program of Study
Degree
Cumulative GPA
Date of Completion

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Short Answer Essay Questions
Please use your own words to write responses of no more than 400 words to each of the questions below. Your answers should demonstrate your compassion, your creativity and your motivation, and should refer to specific examples.
1) Explain how you have managed to succeed in your life despite having to face and overcome hardship.*
Use examples to demonstrate your creativity in doing this.
2) Explain how being awarded this scholarship would help you to contribute to improving the lives of girls and women in the Middle East.*
Use examples to demonstrate what motivates you to do this.

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References
Your application must be supported by three letters of support. Your referees must complete the reference form and return it by email to apply@daughtersforlife.com by the closing date, using the subject of the email Reference for and include your name. For our reference, please provide details of the three referees who will be supporting your application.
Referee #1
Name*
First Last
Affiliation to Referee*
Email*
Contact Phone Number*
Position, Institution*
Referee #2
Name*
First Last
Affiliation to Referee*
Email*
Contact Phone Number*
Position, Institution*
Referee #3
Name
First Last
Affiliation to Referee
Email
Contact Phone Number
Position, Institution

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Financial Needs Analysis
This information will not be made public and will only be used by the Daughters for Life Foundation to help select scholarship recipients. However, you should fill in the form below as completely and accurately as possible, referring to official documentation as you may be required to provide evidence of the information you provide in this section in the future.
Local Currency*
You should use your local currency when answering all questions in this section
1. Current Financial Support
Please tell us about any sources of funding for your current position, or any position (clinical, research or educational) you have received in the last 12 months. If you have not received any in the last 12 months, please leave this blank.
Do/did you receive any other scholarships, grants or outside financial assistance?*
- Yes
- No
If yes, how much do/did you receive?
2. Dependents
Please include details of all dependents (children and spouse) in your family not including yourself - if there are more than 3, please give details of these in 'Other Household Members'.
Dependent #1
Name
First Last
Date of Birth
Name of School/University/College, if any
Cost of School/University/College fees for the year, if any
Total amount received to support
For fees and other school costs, if any (e.g. from grants, scholarships, relatives, charities)
Income
Any funds brought into the household (e.g. through work)
Dependent #2
Name
First Last
Date of Birth
Name of School/University/College, if any
Cost of School/University/College fees for the year, if any
Total amount received to support
For fees and other school costs, if any (e.g. from grants, scholarships, relatives, charities)
Income
Any funds brought into the household (e.g. through work)
Dependent #3
Name
First Last
Date of Birth
Name of School/University/College, if any
Cost of School/University/College fees for the year, if any
Total amount received to support
For fees and other school costs, if any (e.g. from grants, scholarships, relatives, charities)
Income
Any funds brought into the household (e.g. through work)
3. Household Income
Please tell us about any earners in your household. If there are more than 2, please give details of these in 'Other Household Members'. If any section is not applicable, please leave it blank.
Member #1
Member Name
Net Salary (Actual Last Year, Estimated Current Year)
Amount of money earned from working after deducting taxes and social insurance, including bonuses, incentives and profit shares
Net Pension (Actual Last Year, Estimated Current Year)
After deducting taxes
Maintenance Payments (Actual Last Year, Estimated Current Year)
Any funds provided from a parent, guardian or relative who does not live in your household
Net Rental Profit (Actual Last Year, Estimated Current Year)
Any funds earned from renting out a property(ies)
Net Profit on any Bank Accounts (Actual Last Year, Estimated Current Year)
Any interest made from savings or bank accounts
Any other income (Actual Last Year, Estimated Current Year)
Anything not included above, please detail amount and source
Total Income
Sum of above
Member #2
Member Name
Net Salary (Actual Last Year, Estimated Current Year)
Amount of money earned from working after deducting taxes and social insurance, including bonuses, incentives and profit shares
Net Pension (Actual Last Year, Estimated Current Year)
After deducting taxes
Maintenance Payments (Actual Last Year, Estimated Current Year)
Any funds provided from a parent, guardian or relative who does not live in your household
Net Rental Profit (Actual Last Year, Estimated Current Year)
Any funds earned from renting out a property(ies)
Net Profit on any Bank Accounts (Actual Last Year, Estimated Current Year)
Any interest made from savings or bank accounts
Any other income (Actual Last Year, Estimated Current Year)
Anything not included above, please detail amount and source
Total Income
Sum of above
4. Savings
Please complete all sections that apply to the parents in your household.
Parent #1
Total Savings
Total amount of funds in bank and savings accounts
Please explain if and why these funds cannot be used to pay for your university/college attendance
Parent #2
Total Savings
Total amount of funds in bank and savings accounts
Please explain if and why these funds cannot be used to pay for your university/college attendance
5. Outgoings
Please complete all sections that apply to your household.
Rental Payments (Actual Amount Last Year, Estimated Amount Current Year)
Total amount spent on renting out your home for the year
Loan Repayments (Actual Amount Last Year, Estimated Amount Current Year)
Total amount spent on repaying any loans for the year
Medical Costs (Actual Amount Last Year, Estimated Amount Current Year)
Total amount spent on medical costs
Any Other Outgoings (Actual Amount Last Year, Estimated Amount Current Year)
Anything not included above, please detail amount and reason
Total Outgoings (Actual Amount Last Year, Estimated Amount Current Year)
Sum of above
6. Other Household Members
Please tell us about any other dependents or members of your household not already mentioned and any costs and/or income they spend/ earn (e.g. grandparents, children other than the four described above, your husband if you are married).
Other Members not included above

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Declaration
As an applicant you must meet the CPSO’s requirements for licensure as a clinical fellow, and you must also qualify for a working visa for Canada, although you will only be required to apply for these if you are successful. Find more information on U of T’s website: http://pg.postmd.utoronto.ca/applicants/apply-for-fellowshiptraining/. I certify that the above information is complete and accurate as of the date of signing. I acknowledge and understand that providing misleading, incomplete or inaccurate responses in any part of this application may disqualify me from being approved and/or continuing with a scholarship under this programme. Please tick this box to confirm you have read, understood and meet the current requirements for the CPSO and the Canadian work visa.
Consent*
I agree to the privacy policy listed above.
Signed*
Date*
MM slash DD slash YYYY
Email
This field is for validation purposes and should be left unchanged.

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DFL Fellowship Application

Step 1 of 7

Applicant Details

Experience

Education

University/College #1

University/College #2

University/College #3

Short Answer Essay Questions

References

Referee #1

Referee #2

Referee #3

Financial Needs Analysis

1. Current Financial Support

2. Dependents

Dependent #1

Dependent #2

Dependent #3

3. Household Income

Member #1

Member #2

4. Savings

Parent #1

Parent #2

5. Outgoings

6. Other Household Members

Declaration