Scholarship Application
This is not your registration to the conference, this form is for consideration to receive scholarship funds to attend the NW Rural Health Conference. Instructions on how to register will come later if accepted. One application per person is required. You may NOT submit an application to cover a group of people.
Name (First and Last)
*
Title/Position
*
Organization/University
*
Email Address
*
example@example.com
Phone
*
City
*
State/Providence
*
Tell Us Your Story *Explain why you are interested in rural health care and why you want to attend the Northwest Rural Health Conference.
*
Please indicate the item for which you are requesting assistance with.
*
Conference Registration
Hotel Stay
If hotel assistance is needed indicate which night(s)*Scholarship will only cover two nights, if you need additional nights, you will be responsible to pay for yourself.
Monday, March 24
Tuesday, March 25
Additional hotel nights needed *Attendee will be responsible for paying for additional nights requested. Additional room nights are not guaranteed as it depends on availability.
Sunday, March 23
Wednesday, March 26
I understand by applying for this scholarship, I must remain at the conference until Wednesday to fulfill my obligations. Failure to do so will be recorded and may affect future scholarship applications for myself.
*
I agree to these terms
Submit
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