Application for Registration Scholarship

The Preventive Health Collaborative will be covering the cost of several community members to participate in the upcoming AzPHA Spring Conference. Please fill out all information below and submit as soon as possible. A representative from PHC will contact you by February 28, 2018 to notify you if you have received the scholarship. If you have any questions please contact: Alejandra Kisebach, alejandrakisebach@mail.maricopa.gov 

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* 1. First Name

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* 2. Last Name

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* 3. Name of organization you work for and/or represent

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* 4. E-mail

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* 5. Phone number

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* 6. Which Arizona County do you work in?

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* 7. Are you affiliated (partner and/or general member) with any of the following coalitions

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* 8. Are you a Steering Committee Member or on the Leadership Council for any of these coalitions

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* 9. What is your profession

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* 10. Please describe the work that you do and the population that you service

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* 11. How will attending the AzPHA Spring Conference help you in your work and/or advocacy to support children and youth in the state of Arizona and your specific community?

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* 12. Are you a member of AzPHA?

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