Sue Reynolds Fund Application

Sue Reynolds Fund

You may also print the form and mail it to:
Balance for Women Physicians
PO Box 440493
Aurora, CO 80044-0493

For more information contact Dorry Parker at 303-283-6457 (Tel) or at info.balance@comcast.net

Sue Reynolds, MD Memorial Fund Application

Selected candidates (fourth-year medical students) will receive a waiver for tuition ($475 value) plus
$200 toward lodging at the conference. An honorary membership will be awarded, as well, and it is
hoped that candidates will be an active Balance member during the following year.

Deadline: Apply by March 15; notification by April 1.

If you prefer to print this form and mail it, please click here before completing form.

Full Name:

Address:

City:

State:

Zip Code:

E-mail Address:

Telephone or Cell Phone:

Student Status:

Expected Graduation Date:

Medical School:

1. What are your expected plans after graduation?

2. Describe ways in which you feel you can be a contributing member of Balance for
Women Physicians (membership recruitment, committee volunteer, other).

You need Java to see this applet.

Mission & Benefits
Membership Form
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Mentor Program
Request Mentor Form

Balance for Women Physicians, PO Box 440493, Aurora, Colorado 80044-0493

Email: info.balance@comcast.net Tel: 303-283-6457

© 2009 Balance for Women Physicians

Created by Graphic Spring

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Conference Lodge
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