Scholarship Application
MUST READ: 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. If you register for the conference and apply for a scholarship, refunds will not be provided for already paid registrations.
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. *Scholarship will only cover one night, if you need additional nights, you will be responsible to pay for yourself.
Tuesday, March 10
Wednesday, March 11
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.
Monday, March 9
Tuesday, March 10
Wednesday, March 11
Thursday, March 12
I understand by applying for this scholarship, I must remain at the conference until Thursday 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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