Conference Scholarship Application

This form must be filled out completely in order to be considered for financial assistance.
Is this the applicants first time attending an in person Nevus Outreach conference?*

YesNo

Name of Applicant*

First NameLast Name
Email*
example@example.com
Phone Number*
Format: (000) 000-0000.
Relationship to person with Nevus:*
Request for help with - please choose at least one option.*

RegistrationHotelTravel
How many times has the applicant attended a Nevus Outreach conference?
Enter a number 0 - 10
How many times has the applicant received assistance for attending the conference?
Enter a number 0 - 10

Has the applicant hosted a Grassroots Fundraiser for Nevus Outreach?*

YesNo
While grassroots fundraising is not required to recieve a scholarship, an attempt is highly encouraged. Lack of participation may impact scholarship award decisions. Nevus Outreach will guide you each step of the way and make it as easy as possible!

Why would you like financial assistance? *
Submit your reasons for financial assistance here.
I understand that as part of the scholarship process, I may be asked to attend a short call to discuss my needs for financial support.*

Yes, I agreeNo, I cannot do this, and understand that may affect my ability to receive a scholarship.
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