GAP Network: Grief & Advocacy to Prevention Conference Scholarship

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* 1. Please submit the following information:

Name

City

County

Zipcode

State

Email

Phone (Optional)

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* 2. Which Regional GAP Network Conference are you requesting to be registered for?

Jan 12th, 2019 - Northeast Ohio - Cleveland Area

Jan 26th, 2019 - Southwest Ohio - Cincinnati Area

June 1st, 2019 - Central Ohio - Columbus Area

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* 3. Select the boxes below that apply to you.

Grieving a loss loved one.

Prevention Professional

Social Worker

Counselor

First Responder

School Teacher

Other (please specify)

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* 4. Why do you wish to attend the Grief & Advocacy Conference?

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* 5. If others are joining you and you would like to submit a scholarship request for them, please submit their information below if you have it.

Name

City

County

Zipcode

State

Email

Phone (Optional)

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* 6. We will review and respond to your request via email within 24 hours that it was submitted. Once approved, this form will enable you to be registered with no cost. Thank you for taking the time to fill this form out. Let us know below if there are any questions or concerns about the conferences you wish to attend.