AELPS Application Form

Seats are limited. After the application deadline (January 15, 2024), all applicants will be reviewed for examples of leadership, plus a passion and commitment to patient safety and quality.

  • Medical/Nursing/Pharmacy Students –
    • Full scholarships for U.S. students are available and include airfare, lodging, ground transportation, educational materials, scheduled group outings, and most meals.
    • International student applicants will be considered for the Maryland session and need to pay and book airfare.
    • Nursing Student Scholarship Eligibility: Applicants must be
      • actively practicing
      • have between 3-10 years nursing experience post-licensure
      • enrolled in a graduate nursing program at the time of the program
  • Residents-
    • Through the generosity of COPIC, a limited amount of full scholarships are available for residents practicing in the states of Arizona, Arkansas, Colorado, Iowa, Minnesota, Nebraska, North Dakota, Oklahoma, South Dakota, and Utah.
    • All others must have residency program funding.
    • International resident applicants will be considered for the Maryland session and need to pay and book airfare.

Please contact AELPS_Support@medstar.net for more details.

    Your Name

    Please indicate medical student, nursing student, pharmacy/health science student, or resident physician

    Medical/nursing/pharmacy/health science students: please indicate your school.

    Nursing students: please indicate your years of nursing experience, the graduate program you are enrolled in, and expected graduation date.

    Resident physicians: please name your residency program and specialty.

    Your Email

    Your Backup Email (i.e. Gmail, Yahoo)

    Street Address

    City

    State

    Zip Code

    Your Phone Number

    How did you hear about The Academy for Emerging Leaders in Patient Safety?

    Gender (for lodging assignments)

    Please provide 1st choice of location you would like to attend

    Please provide 2nd choice of location you would like to attend

    Please provide 3rd choice of location you would like to attend

    Please Upload Your CV:

    Please provide a one-page personal statement telling why attending The Academy for Emerging Leaders in Patient Safety is important to you:

    Please Upload Letter of Recommendation. (See Letter of Recommendation Guidelines):

    If you do not have a Letter of Recommendation at this time, it must be submitted before the application deadline. Please indicate when we can expect it:

    Should you be accepted, the following information is necessary to assist with your travel and lodging arrangements:

    Date of Birth (mm/dd/yyyy)

    Preferred home airport (or N/A if you're local and will be driving)

    Necessary special accommodations or dietary restrictions (please indicate "none" if there aren't any)

    Media Release: Please read and acknowledge that you accept terms