City Host Application

International Fellowship Program: City Host Application

Application Deadline – June 1, 2008

	1. Name of individual submitting application:
	Name:
	Title:
	Employer:
	Street Address:

	City:
	State:
	Zip:
	Telephone:
	Fax:
	E-mail:

	2. Will you be the City Coordinator? Yes No If No, who will be the City Coordinator?
	Name:
	Title:
	Employer:
	Street Address:

	City:
	State:
	Zip:
	Telephone:
	Fax:
	E-mail:

	3. Host City/Metropolitan Area that will be participating:


	4. Please indicate the institutions and organizations from the above city/metropolitan area that are willing to participate:
	Hospitals List hospital name, number of beds, and contact person who will serve as an institutional host.
	Schools List school name, type of program (one-year, two-year, four-year) and contact person who will serve as an institutional host.
	Home Care Organizations List the name of the organization, type of service, and contact person who will serve as an institutional host.
	Other Institutions (SNF, specialty lab, hospice, group home, clinic, etc.) List the name of the institution, type of service, and contact person who will serve as an institutional host.

	5. Please indicate a medical director of respiratory care who will be willing to meet with the Fellows and informally discuss respiratory care in the United States.
	Name:
	Title:
	Institution:
	Street Address:

	City:
	State:
	Zip:
	Telephone:
	Fax:
	E-mail:

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