*

First Name

Last Name

Are you currently working in the UK? *

Only UK junior doctors and allied health professionals are eligible for the fund

Yes

What is your current position? *

Only non-consultant junior doctors and allied health professionals are eligible for the fund

Haematology trainee

Non haematology junior doctor

Allied health professional

Have you received a grant from the ISTH Legacy Fund before? *

Yes

No

Date previous ISTH fund received

If applicable

MM

DD

YYYY

Presenting work

Oral presentation

Poster

Not applicable

Would you be willing to support promotion of HaemSTAR at the event (e.g. assist at HaemSTAR charity stand and promote HaemSTAR projects)? *

Not applicable if the application is after the event

Yes

No

Not applicable

I confirm I am committing to writing about my experience at the event as a blog on the HaemSTAR website following the event *

Please refer to blog page for examples

Yes