*Please indicate your FULL name (First and Last)(Required.)

*Please indicate your Institution & Position Title(Required.)

*Are you an OACUHO member? NOTE: This scholarship is only open to OACUHO members(Required.)

Yes

No

*Please enter your email address:(Required.)

*Please indicate your telephone number:(Required.)

*In 250 words or less, please explain why have you chosen to apply for a scholarship for this workshop:(Required.)

*In 250 words or less, please explain why you would like to attend the Diversity and Inclusion Workshop, and how it will benefit you in your current position:(Required.)