2020 Annual Conference Registration Scholarship Application

ADCES20 Annual Conference

Scholarship Award: Complementary registration to attend the ADCES20 Annual Conference & Exhibition.

Please read the entire application before completing it. We encourage you to take your time and answer the questions with as much detail as you are able.

Eligibility:

Applicant must be an active member of ADCES (formerly known as AADE) for at least two years at time of submission.
Invited speakers are not eligible for scholarships.
Applicants are only eligible for a scholarship award once every three years.

Submission Requirements, Scoring Criteria and Important Dates:

Applications MUST be submitted no later than March 2, 2020. Please be sure to provide as much detail as possible in your answers
Scholarships will be awarded by March 31, 2020 by email.

GENERAL INFORMATION

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* 1. First Name

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* 2. Last Name

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* 3. Credentials

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* 4. ADCES Member Number

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* 5. Home Address

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* 6. City/State/Zip

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* 7. Work Phone

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* 8. Home/Cell Phone

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* 9. E-Mail Address

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* 10. Employer

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* 11. Are you affiliated with a state CB or LNG?

Yes

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* 12. If Question 11 is "yes", please name

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* 13. What is your race? (Please select all that apply)

Afrcan American/Black

Hispanic or Latino

American Indian or Alaska Native

Native Hawaiian or other pacific islander

Asian

Caucasian/White

Other

Prefer not to answer

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* 14. Is this your first application for a scholarship from ADCES (formerly known as AADE)?

Yes

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* 15. If Question 14 is "no", what years did you apply in the past?

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* 16. Will this be your first time attending the ADCES Annual Meeting?

Yes

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* 17. If Question 16 is "no", how many ADCES Annual Meetings have you attended over the last 10 years?

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* 18. What is the number of employees dedicated to diabetes education in your workplace, including you?

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* 19. Have you had an abstract accepted for the upcoming Annual Meeting?

Yes

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* 20. If Question 19 is "yes", please indicate in what area.

Concurrent session

Poster session

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* 21. Does your employer assist with Annual Meeting expenses?

Yes

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* 22. If Question 21 is "yes", please indicate what your employer will pay.

Employer pays registration only

Employer pays registration, travel and/or accommodations

Other (please specify)

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* 23. Financial Need Statement. In 150 to 200 words, please explain your need for financial support.

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* 24. Population Served Statement. In 150-200 words, please describe the population with which you work.

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* 25. How many hours per year do you volunteer - without pay and off duty - promoting / providing diabetes education?

0 hours per year

1 - 24 hours per year (3 x 8 hour days)

25-40 hours per year (5 x 8 hour days)

41 - 80 hours per year (10 x 8 hour days)

80+ hours per year

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* 26. List and describe examples of diabetes care and education related volunteer work (local and national) non-ADCES diabetes activities or local ADCES affiliate Coordinating Body or Local Networking Group activities and/or ADCES national activites you have been involved with over the last calendar year (January - December). Include committee work, task forces, presentations, projects, authorship, participation in National Diabetes Education Week, and leadership roles over the last calendar year.

If you need additional space, continue on Question 27.

Activities must be voluntary and unpaid.

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* 27. If needed, additional space from Question 26.

Consent to Eligibility Requirements and Contributions

By submitting an application, I understand and agree to abide by the entry and eligibility requirements indicated. I understand that all materials submitted in conjunction with the scholarship application will not be returned.

I agree that, if selected, highlights from the application may be used by ADCES for such purposes as sharing best practices, advertising, publicity, and promotion for or solicitation of future applications. I agree to submit a post-event testimonial (written, recorded, or video-taped) as requested in accordance with the timeline established.

I also understand that, if seleced and I fail to respond to the deadlines for submitting the necessary information to process the registration scholarship, I will forfeit receipt of the scholarship. Staff will provide the important deadlines upon receipt and notification.

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* 28. Please upload your CV

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