Healthy Resident Program

Contact Details:
Family Name: First Name: Email: PGY Level:
Program Address: City: Province: Postal Code:
Funding Details:
Name of Project: Funding Request Amount:
Residency Program:
Number of Residents in Residency Program: 
Mandate to promote (select all that apply):
Lounge upgrades
Healthy snacks/dining
Sports event/team

Other (please explain):
Expected Start Date: Expected Completion Date: 
Describe the expected outcomes of this initiative and how you will measure its success?
How will the funds primarily be used? (Provide detailed budget)
How would you promote this initiative to the residents in your program?
Other information:
Privacy Information:
Additional supporting information can be sent via email to

Contact Name : Date Signed :
I verify that all of the information is accurate and that I am the person named above.