KYACHW 2026 Scholarship Request Form

KYACHW Membership & Conference Scholarship Request Form

Join Kentucky's leading network of Community Health Workers. This application is for CHWs who do not receive financial support from their employers for membership or to attend the annual KYACHW conference. Please note that if you are selected to receive the scholarship, you will need to pay your costs (registration, hotel, mileage) up front and save your receipts to submit after the conference.
Full Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer/Organization Name
Position/Title
Work Address
How long have you been a CHW?
Is your employer paying for OR reimbursing any costs?

A. Yes (answer question below)B. No (answer question below)
A. If yes, what is your employer paying for?
What item(s) below are you asking for reimbursement?

New MembershipMembership RenewalConference RegistrationLodging
How did you hear about the KYACHW?
Is there any topics you would like to learn more about at the conference?
If you have any questions, please feel free to reach out to Angela McGuire @ angela.mcquire@uky.edu.

Sam Bowman with Membership @ samantha.bowman@uky.edu

Please submit your request for scholarship by June 30, 2026

Upon board review you will be notified if approved.

Please Note:

Attendance at the conference is REQUIRED. Make sure you are a paid member.

Checks will be mailed within approximately 30 days after receipt of travel. Please submit your receipt to the address below:
KYACHW
750 Morton Blvd.
Hazard, KY 41701
Should be Empty:

KYACHW Membership & Conference Scholarship Request Form