The International Liaison Committee of the
International Neuropsychological Society
Charles Matthews Support Fund
Application for Video/teleconferences and Invited Speakers
The International Liaison Committee (ILC) of the International Neuropsychology Society (INS) accepts applications for funds to support electronic conferences or invited speakers in neuropsychology. The purpose of this program is to promote continuing education among neuropsychologists in non-North American countries, especially South America, Asia, Africa, and Eastern Europe.
Funds may be used to support the following:
- organizing and administrative expenses (e.g., printing, postage, supplies, institutional fees)
- travel expenses for invited speakers
- honoraria for invited speakers
- translation services
- technology services or fees (e.g., phone calls, equipment rental)
- site rental
Recipients and the amount of support provided will be selected based on need as well as on the merit and usefulness of the proposed program. Applicant organizations must agree to provide a financial account for funding and a summary report of the event.
Recipients will be notified by _______________
The final report is due by _______________
Please send application letter and supporting materials in electronic or paper
format to:
Dr. Mariana Cherner, PhD
Chair, ILC
E-mail: chair@ilc-ins.org
(Applicants must use this form and submit it typed via email or postal
mail)
Date: ___________________
Applicant Organization Name:
__________________________________________________________
Mailing Address:
Zip: ____________
Describe the specific program to be funded (objectives, activities, and preliminary program):
Specifically, how will the funds be used? State the specific goals you wish to achieve and describe the activities that will take place to reach those goals:
Program Title:
Program Director:
Phone: Ext:
Program Director(s) email address:
When will the Program take place?
Start: End:
Please note funding will not be distributed until after ____________.
Amount requested (not to exceed $ ) $
Total funding required for this Program: $ ________________
Geographic area to be served by this Program:
Estimated number to be served:
Describe accommodations for invited speakers:
Audio/visual and electronic equipment and support needed:
Audio/visual and electronic equipment and support to be provided by host organization:
Meeting site and/or videoconferencing facilities needed:
Meeting site and/or videoconferencing facilities to be provided by host organization:
Translation services needed:
What other facilities, services, equipment, or resources will be provided by the host organization?
Publicity planned to promote the event:
How will you evaluate and measure the impact of this program?
Expenses
Total Budget for the Program
Portion of budget to be supported by INS Matthews Fund
Personnel/Staff
a) Administrative $ $
b) Teaching (including aides) $ $
Total Personnel/Staff $ $
Outside Fees and Services
a) Consultants $ $
b) Other $ $
Total Outside Fees and Services $ $
Remaining Operating Expenses
a) Supplies/Materials $ $
b) Other (please list---travel, technology, translation services, etc.) $ $
Total Remaining Operating Expenses $ $
TOTAL CASH EXPENSES $ $
You will be required to provide a follow-up report. Please include the following information:
• Description of target audience
• Estimate of people in the area who are in the target audience
• Total number of people who attended
• Number of INS members attending and membership status • Number of students attending
• Highest degree level of people attending (BA, MA, PhD, MD, etc.)
• Participant evaluation of learning goals
• Evaluation of overall neuropsychological community change goals
Program Director’s Signature and Date
___________________________________________
INS/ILC Official’s Signature and Date:
___________________________________________