Travel Award Sponsored by Dr. Dolittle

Full Name

Section Affiliation

Email

Phone Number

APS Membership Number

EB Abstract Number

I have received written consent from all other contestants or people over 18 years of age who are featured in my video, blog text, or photos and can produce that written consent on request.

Yes

Not applicable

I have received written consent from the parents or guardians of each person under 18 years of age who is shown in my video, blog text, or photos and have uploaded the signed consent form(s) with my application.

Yes

Not applicable

I have received appropriate written permission(s) to film on any sites shown in my video, blog text, or photos (e.g., campus, departmental buildings, laboratories) and can produce the written consent on request.

Yes

Not applicable

I have written permission of the institution and IACUC approval for any laboratory animals used in the video, blog text, or photos.

Yes

Not applicable

I have received professional assistance in producing this video, blog text, or photos.

Yes

No

This video, blog text, or photos is original and unique work.

Yes

No

My video, blog text, or photos DO NOT contain: (leave un-checked any items your video does contain)

the APS logo, name, or website

Copyrighted material that is not owned or licensed by myself or another contestant or is not in the public domain

Trademarks of any third-party domain

Third-party voiceovers

Third-party stock photos, artwork, video, or sound unless that is not licensed by myself or another contestant or is not in the public domain

Nudity, lewd or vulgar behavior, offensive language and/or gestures

Exploitation or mistreatment of humans or animals

Please cite all your sources of reference materials used in developing the content of the video, blog text, or photos. Be sure to include the complete citation (Title, authors, chapters, pages, publisher, website, etc.).

Started submitting an abstract for the 2025 American Physiology Summit but didn’t finish? Finalize it today!

Travel Award Sponsored by Dr. Dolittle Form

Blog Compliance Form & Source Reference Sheet

Please certify the following items:

Source Reference Sheet

Quick Links

Contact Us