SLF Nomination Form

Sarah Loguen Fraser, MD, Class of 1876 Scholarship

This nomination form is intended for faculty and staff to nominate a current student based on the eligibility requirements listed below.

If you have questions regarding this application form, contact Ellen at (315) 464-4361 or edgertoe@upstate.edu.

Eligibility

First or second year medical students at Upstate Medical University are eligible. The student must hold similar ideals to Dr. Sarah Loguen Fraser. The award is principally based on need, but the recipient must also have a genuine desire to provide service to the medically under-served. Strong candidates for this award should also have demonstrated leadership qualities and a willingness to give of themselves through volunteer work or other efforts that make a positive impact on the lives of others.

Nominee Information

First Name*

Last Name*

Class Year*

Although not necessary, use the below area to include additional information about the nominee.

Nominator Information

Nominator Name*

Title*

Email*

Phone Number

How do you know the Nominee?*

Signature

I understand that the information contained in this application is for the purpose of the Medical Alumni Foundation to evaluate and consider my nomination for this student to receive a scholarship. I understand that the Medical Alumni Foundation and Scholarship Committee may contact me or other officials at Upstate Medical University to discuss this nomination.

I agree to terms above*

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Name

SLF Nomination Form

Sarah Loguen Fraser, MD, Class of 1876 Scholarship

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Upstate Medical Alumni Foundation

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