NEPQR CFPA Stipend Request Form

Region 8 NEPQR CFPA Professional Development Support Stipend
Please note that this opportunity is only available for participants living and or working in the state of Montana.
Name

First NameMiddle InitialLast Name
I can confirm that I am living and/or working in the state of Montana. This opportunity is only available for participants who are living and/or working in Montana.

Yes
Organization
Job Title
Phone Number
Please enter a valid phone number.
E-mail
example@example.com
Conference Selection:

Confluence 2026 (April 14-16)2026 Western Institute of Nursing (April 21-24)Montana Hospital Association's 2026 Summit (Oct. 6-9)Rocky Mountain Tribal Leaders Council Public Health Conference 2026 (dates pending)
Required Reporting Information

This stipend will be provided to you due to funding made available through the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS). We are required to provide demographic information of all participants. All identifiable information will be removed and replaced with unique identification number and your identity will remain anonymous. Thank you for your participation!
Are you a Registered Nurse?
Discipline or Speciality
Highest Degree of Education Obtained
Employment Status

Full TimePart TimePRNCurrently Not EmployedOther
Year of Birth
Gender
Race (please select all that apply)

American Indian/Alaskan NativeBlack/African AmericanAsianNative Hawaiian/Other Pacific IslanderWhiteI do not wish to report
Ethnicity

Hispanic and/or LatinxNon-Hispanic/Non-LatinxI do not wish to report
Are you from a Rural Residential Background?

YesNo
Are you from a Disadvantaged Background?

YesNo
Are you a United States Veteran?

YesNoCurrently Serving
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Region 8 NEPQR CFPA Professional Development Support Stipend

Please note that this opportunity is only available for participants living and or working in the state of Montana.