Scholarship Chronic Disease Forum & Cardiovascular Disease Summit 2017

Scholarship Request Form

This conference will focus on strengthening partnerships and integration of clinical care and population health through improvements in a coordinated quality health care system in Arkansas with a special emphasis on cardiovascular disease.

A limited amount of scholarship money is available for the 2017 Arkansas Chronic Disease Forum so requests will be considered on a first come, first serve basis. Scholarships may be used toward the registration fee ($75). In order to be considered for a Forum Scholarship, this form must be received no later than April 1st. No requests will be considered after this date.

Scholarships will be given according to the following criteria:
•Five (5) community advocates from non-profits and coalition members unaffiliated with state, federal or local agencies, and

•Five (5) students from the UAMS School of Nursing, School of Pharmacy, College of Public Health and Clinton School of Public Policy and those involved in Heart-to-Heart Sweethearts.

Scholarship awardees will be expected to assist event organizers before and after the forum.

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* 1. Please enter your information:

Participant Name:

Organization Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

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* 2. Reason for Scholarship request:

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* 3. How would you characterize your organization?

Public/Government

Educational Institution

For-Profit

Non-Profit/501c3

Community Coalition

Grassroots Advocacy

Other (please specify)

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* 4. Scholarship awardees will be expected to volunteer by assisting event organizers before and after the forum. Please select a volunteer station below.

Registration

Conference Set Up

Conference Breakdown

Other (please specify)