CHIA FAME Scholarship Application

CHIA Foundation for Active Member Education (FAME) Scholarship Application
For more information about eligibility and full requirement details, visit https://californiahia.org/scholarship-programs.

Applications may be submitted anytime during the year, but must be received by CHIA at least 30 calendar days in advance of the desired program.
Name*

First NameLast Name
Credentials
AHIMA/CHIA ID Number*
CHIA Membership Status*

Professional MemberProfessional Emeritus Member
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*

Area CodePhone Number
Email*
I am requesting the FAME Scholarship for the following:

Complete only the expense categories that you are requesting. Expense amounts entered will be auto-totaled at the end of this section.
CHIA-sponsored Educational Program*
Program Location*
Program Start Date*

MonthDayYear
Program End Date*

MonthDayYear
Registration Fee Expense*
(at the early CHIA Member rate)
Ground Transportation Expense:
Total Roundtrip Miles
IRS Mileage Rate
$0.67, eff Jan 2024
Ground Transportation Total
Coach Airfare Expense:
From Airport:
To Airport:
Airfare Total
Lodging Expense:
Hotel Name
Number of Nights
Daily Rate
Lodging Total
Meals Expense:

Daily maximum is $66; Breakfast = $16 & Lunch = $17; Dinner = $28 tips and incidentals = $5.
Meals Total
Total FAME Scholarship Expense Amount Requested:

Auto-totals expense amounts entered above.
Total Amount Requested:
Narrative Responses:

Provide a brief response (50-150 words) to the following questions.
I wish to attend this CHIA educational program because:*
I am seeking financial assistance through the FAME Scholarship to attend this CHIA educational program because:*
My attendance to this CHIA program will help me in my current HIM position and/or help me attain my professional goals in the following way(s):*
My involvement in HIM professional activities and/or committees at the national, state, and/or local level include:*
Format: Date Range, Activity/Committee, Organization (Ex: 2017-18, CHIA Awards Cmte, CHIA)
I certify that the information submitted with this application is accurate and I authorize CHIA to validate its accuracy:*

Clear
Signature
Should be Empty:

CHIA Foundation for Active Member Education (FAME) Scholarship Application