Bursary Application Form for Fertility 2018

Your Contact Details

Title *

First name *

Surname *

Email Address *

SRF Membership

SRF Membership Category - REMINDER - Non-Statutory Full, Early Career (ECM)* and Retired Members who have been SRF Members for at least 2 membership years (i.e. must have been a member in 2017 and renewed and paid for 2018) are eligible to apply. * The requirement for the 2 membership years will be waived for ECM Members in the first year of their PhD or at BSc/MSc education levels. Honorary Members may also apply.

SRF Membership Category *

*If you are an Early Career Member in the first year of your PhD OR are at BSc or MSc education levels, please tick the box below and provide the details of your Supervisor. The SRF will automatically contact your Supervisor to verify your status.

I am in the 1st year of my PhD studies OR am at BSc or MSc educational level of my studies

Supervisor's Title (Prof/Dr etc.) *

Supervisor's Surname *

Supervisor's Email Address *

NOTE to ALL REPRODUCTION EDITORIAL BOARD MEMBERS (applies to both SRF Members and Non-Members)

Please enter your SRF Membership ID: *

BURSARY PART 1 - REGISTRATION REQUIREMENTS

Please indicate the type of registration you will require for Fertility 2018. (Please note that by ticking this box you will not automatically be registered for the conference. Subject to your application being approved you will need to register for the Fertility 2018 through the online registration process once you have been issued with the relevant discount code).

Please indicate the type of registration you will require for Fertility 2019 *

Full Conference Member Registration

One Day Member Registration

Student Member Registration**

**Student Member Registration applies to undergraduate, unsalaried students ONLY. The rate entitles Students to attend the full conference.

If you plan to book a 'one-day' registration, please indicate the day(s) you will attend. If you are planning to attend all days you should select Full Conference Member Registration or Student Member Registration from the options above. *

Thursday 3 January

Friday 4 January

Saturday 5 January

Will you be attending the Conference Dinner on the evening of Friday 4 January? *

Yes

No

BURSARY PART 2 - ACCOMMODATION

For those who live within 10km of the conference venue (ICC Birmingham) accommodation costs cannot be covered. For those living outside of Birmingham, the SRF will pay a fixed cost of £100 per night up to 3 nights. A copy of receipts may be requested after the conference.

I live in Birmingham and understand that I am not entitled to claim a bursary towards accommodation costs

Please tick if appropriate

I do not live in Birmingham and will be booking accommodation for the following number of nights:

1 night

2 nights

3 nights

BURSARY PART 3 - TRAVEL

Travel support is offered on a fixed band system on distance from your place of work and will be calculated as follows: <10 km: £0; 10 - 100 km: £30; 100 - 300 km: £75; 300 - 500 km: £150; 500 - 750 km: £200; 750 - 1000 km: £300; >1000 km: £400

Work address *

Town/City *

Postcode/Zipcode *

County/State

Country *

Visa - Will you require a visa to travel to Fertility 2019? *

Yes

No

PLEASE NOTE: funds for travel and accommodation will only be paid once the Secretariat has received confirmation from you that your visa application has been successful

Disclaimer *

I confirm that I have read and understood the terms and conditions relating to the award of a Fertility bursary as detailed on the SRF website http://srfnew.wpengine.com/grants-awards/terms-and-conditions/.

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Your Contact Details

SRF Membership

BURSARY PART 1 - REGISTRATION REQUIREMENTS

BURSARY PART 2 - ACCOMMODATION

BURSARY PART 3 - TRAVEL

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