Access Scholarship Application
Complete this form to apply for a scholarship to attend the symposium and learn about available registration options, session interests, and accessibility needs.
First Name
*
Last Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Organization/Company
Job Title/Role
City
*
State
*
ZIP Code
*
Please select your affiliation or category (check all that apply):
*
Frontline Worker
Tribal/Native-serving participant
Community Health Worker
Substance Abuse Worker
Peer Support Specialist
Youth-serving provider
Caregiver
Reentry participant
Under-resourced community-based organization
Student/Intern
Other
Why are you requesting scholarship support?
*
What symposium sessions or tracks are you most interested in attending?
*
Do you need no-cost registration or reduced-cost registration?
*
No-cost registration
Reduced-cost registration
Are you requesting CE (Continuing Education) credits?
Yes
No
Do you need accessibility accommodations? If yes, please describe.
How did you hear about the Community Access Scholarship?
I understand that scholarship seats are limited. If selected, I commit to attending the symposium or notifying the organizers if I am unable to participate so my seat can be offered to another applicant.
*
I acknowledge and agree
I consent to receive event updates and communications related to the symposium.
*
I consent
I confirm that the information provided in this application is true and accurate to the best of my knowledge.
*
I confirm
Submit Application
Should be Empty: