Scholars' Program Nomination Form - Pediatric Candidate (1)

Thank you for your interest in the Scholars' Program. Please fill out the required information below.

 

We strongly suggest using the latest versions of Firefox, Safari or Google Chrome. Please ensure that all documents are submitted in PDF format and contain no special characters in the file name, including punctuation.

 

PLEASE NOTE that you must submit the online nomination form, in one single step. You are not able to save your form and return to it at a future date, rather it must be completed all at one time.

 

RCPSC Gastroenterology Pediatric Program Director Information

If there is no Pediatric GI training program at your center, the Pediatric Gastroenterology Division Head or General Pediatrics Program Director is authorized to submit the candidate.

Pediatric Candidate (may submit one)

Must be a med student Y3-Y4 or pediatric resident (PGY1-PGY2). Candidate must also be a CAG member or have applied to become one by October 21.

Electronic Signature

By checking this box and typing my name, I certify that I am the person accessing this webpage, submitting this form, and that all information on this form is true and correct.  I also agree that the checkbox and my name typed below are to be used as my electronic signature.

 

Please click on the "Submit" button to submit your nomination for the Scholars' Program. Before submitting, please ensure you have filled out all of the mandatory fields and all attachments are correct.

 

Upon successful submission you will be directed to a webpage that confirms the successful submission and within a short period of time you will receive an email from the CAG National Office confirming receipt of your submission.  If this does not occur, please contact the CAG National Office.

 

NOTE: Upon submission do not close your browser or use the back button until the "Thank You" screen appears confirming your submission has gone through. Uploading of large files may take a minute or so.