Travelling Specialist Support/Funding Form - The Western Canadian Children’s Heart Network

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Travelling Specialist Support/Funding

For Healthcare Providers / Travelling Specialist Support/Funding Form

Requestor

Name *

First

Last

Title and Affiliation

Email *

Phone:

Travelling Specialist

Type of Travelling Specialist Funding (select all that apply) *

Locum - Licensing and Registration
Locum - Travel and/or Accommodation
Travelling Specialist Clinic
Travelling Specialist Services

Name of Travelling Specialist *

First

Last

Title and Affiliation

Email

The Trip

Proposed Dates of Travel - Departing

Proposed Dates of Travel - Returning

Travelling From

Travelling To

Purpose of the Trip *

Benefit/Impact *

Describe why this trip is important/helpful to patients, families, and/or teams, and estimate the number of people benefiting from this trip.

Detail

Amount Requested/Estimated (CAD) *

Will supplemental funding be pursued, or has it been secured already?

Yes
No

List additional (potential or confirmed) funding source(s)

Is a concurrent education session planned?

Yes
No

Please provide details about the concurrent education session

Who is it designed for? How will it be delivered? What are the intended outcomes?

Name of person completing this form *

First

Last

For Office Use Only

Decision Notice

Pending
Approved in full
Approved with caveat
Declined

Optional Text

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The Western Canadian Children’s Heart Network

Contact Us

College Plaza, Suite 1910
8215 112 Street NW
Edmonton, AB T6G 2C8
Canada

wcchn@ahs.ca
(587) 782-3259

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The WCCHN respectfully acknowledges that Indigenous peoples are the traditional guardians of Canada. We acknowledge that this land is unceded and that each health authority we work with has a duty to acknowledge their relationship to the land upon which they live and work. The information on this website does not constitute and should not be taken as medical advice. Always consult with your child’s cardiologist or care team for specific guidance and information.

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Our Organization
Our Partner Hospitals
For Parents & Families
Your Child’s Surgery

Getting Prepared

At the Stollery

At BC Children’s

Financial Planning

Packing Guide

Knowledge

Fetal Cardiology

Surgery & Treatments

Living with CHD

Developmental Care

Transitioning to Adult Care

Grief & Bereavement

View All Resources

Community

Finding Support in Your Province

Caregiver’s Corner

Family & Patient Stories

The Story Corner

Camps for Fontans

Thank a Staff Member

BoostUp Pitch Competition
For Healthcare Providers
Contact