NABPT PT Month Scholarship Application

CAPP Course Scholarship

Sponsored by National Association of Black Physical Therapists (NABPT) and the Academy of Pelvic Health Physical Therapy (APTA Pelvic Health)
Submission Date*

MonthDayYear
Date
Name*

First NameLast NameCredentials
Email*
example@example.com
Phone Number*
Member of NABPT (required for selection)*
I am a...*
Graduation Month/Year *
DPT/PTA Program
Mailing Address*

Street Address

Street Address Line 2

CityState

Postal / Zip Code
Headshot: If selected as the recipient, this photograph will be utilized to announce your award. *

Please upload a headshot.
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Video Statement: Submit a maximum 3 minute maximum, video statement describing your vision for the future of pelvic health. Please include how you plan to contribute to the profession while fostering a welcoming environment and sense of belonging. *

Maximum 3 minutes, ideally 60 seconds
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Blog Entry (300-600 words): Please provide us with information on the following: your educational/professional background, contributions to the field, what made you pursue this profession, and what drives your passion to the field of pelvic health physical therapy.
Community Influence: In 1-2 paragraphs, please share in what specific ways will you use this scholarship opportunity to influence your community and profession. How will this scholarship help you?*

0/300
Special Considerations: Is there anything else we need to know or should consider when reviewing your application?
Course Availability is listed below. Please note that you should select your interest in One Course. Your selection can be for an In-person OR Webinar Course that you would be interested in attending as a scholarshp recipient. Again, please remember to only make ONE selection.
Webinar Courses
In-Person Courses
CV/Resume (Optional)

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Signature:

By providing my full name below, I certify that the information provided on this form is true, accurate, and complete. I understand that any false statements or intentional omissions may result in cancellation of my scholarship application.

If selected as a recipient, I grant permission for the Academy of Pelvic Health Physical Therapy (APTA Pelvic Health) and the National Association of Black Physical Therapists (NABPT) to sue my name, photo, video entry, blog entry, and scholarship announcement in official marketing, communications, and promotional materials.

I also acknowledge and agree to the following conditions:
- Non-Transferability: Scholarship awards are non-transferable and must be used within the calendar year awarded, unless otherwise approved n yNABPT and APTA Pelvic Health
- Travel and Participation: If the award includes a travel stipend, reimbursement is avaialble through the Academy's Scholarship Travel Expense Reimbursement Form. I am soley responsible for my own travel arrangements, safety, and participation in the courses.
- Program Changes: The scholarship program may be changed, postponed, or calnceled due to circumstances beyond the control of NABPT or APTA Pelvic Health (e.g. natural disasters, pandemics, venue closures). In such cases, both organizations will work in good faith to provide alternate opportunities, but fulfillment cannot be guaranteed.
- Liability: NABPT and APTA Pelvic Health are not responsible for personal injury, property loss, or other claims arising from my participation in any course or travel related to this scholarship.
- Event Participation: I have read, understand, and agree to the APTA Pelvic Health Event Terms & Conditions
Signature: *

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CAPP Course Scholarship