Parkinson's
Disease Pharmacotherapy Traineeship
Traineeship
Application
To
submit the Traineeship Application electronically, click
here to complete the online form and follow the instructions
as specified. You may also submit the form by postal mail
by following the directions located at the bottom of this
form.
| Name |
| Employer/Company
Name |
| Preferred
Mailing Address |
| City,
State, Zip |
| Telephone |
Fax |
E-mail
|
SESSION
PREFERENCE: Preferences
will be taken into consideration, but cannot be guaranteed.
Submission of an application indicates an ability to
attend either traineeship session. Please check:
| June
2-6 |
September
15-19 |
No
preference |
ADDITIONAL
APPLICATION DOCUMENTS REQUIRED: The following items of
information are to be appended to this form, each
clearly labeled in the upper right-hand corner, as indicated
(Exhibit A, Exhibit B, Exhibit C):
Exhibit
A. Curriculum vitae, including the applicant's education,
experience record in pharmacy practice (in reverse chronological
order, most recent first), and any relevant publications,
presentations, and
community service.
Exhibit
B. A statement of not more than three typed, double-spaced
pages describing (1) why the applicant wants to participate
in the
traineeship and the applicant's expectations of the traineeship
experience; (2) nature and extent of professional or personal
involvement with persons with Parkinson's disease and other
neurological disorders, caregivers, or family members; (3)
current level of clinical services provided by the applicant,
including total number of patients served, geographic distribution
(urban, rural, suburban), ethnic distribution (Black, White,
Hispanic, Asian/Pacific Islander, American Indian/Eskimo/Aleut),
and number of patients with Parkinson's disease; (4) special
services or programs provided by the applicant; (5) how
the traineeship will enhance the pharmacy services currently
provided; and (6) how the results of the traineeship experience
will be incorporated into the applicant's practice.
Exhibit
C*. A letter from the applicant's employer confirming
support for the applicant's participation in the
traineeship
and willingness to implement the results of the traineeship.
The letter should be addressed to the applicant and
signed
by the chief executive officer, director of pharmacy, clinical
coordinator, or other appropriate manager/supervisor
in
the organization.
*If the applicant is self-employed, this
exhibit may be omitted.
|
Applicant
Signature
|
Date: |
If submitting by mail, send the completed application form and
attachments to: ASCP Foundation, 1321 Duke Street, Alexandria,
VA 22314.
