SHSMD Bytes Virtual Conference Scholarship Request

Scholarship priority will be given to SHSMD members.

Please complete this form no later than October 13.

The Scholarship Program is generously sponsored by Prairie Dog.

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* 1. Contact Information

Name *

Organization *

Title *

City/Town *

State/Province *

ZIP/Postal Code

Country

Email Address *

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* 2. Are you a member of SHSMD?

Yes

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* 3. Organization type, please select all that apply.

Academic Medical Center

Critical Access Hospital

Health System

Rural Hospital or Health System

Standalone Hospital

Other (please specify)

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* 4. Briefly describe your role and experience

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* 5. Describe your financial need.

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* 6. How will attendance benefit you and what part of the curriculum has special relevance for your work?

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* 7. Additional comments

Thank you, your request will be reviewed and processed. Those receiving scholarships will be notified by October 20.