Scholarship Application
Building Healthy Futures Conference
April 26th - 27th in Richmond, VA

The Action Alliance is committed to prioritizing the work and voices of those who have been historically marginalized and oppressed in society and in our movement. As such, we seek to create learning opportunities that are accessible to our diverse membership and allies and are offering a limited amount of scholarships to help cover the cost of registration ($135 for members // $165 for non members) for the 2017 Building Healthy Futures: Linking Public Health & Activism to Prevent Sexual & Intimate Partner Violence Conference to assist those who would not be able to attend otherwise.

To lift up our commitment to becoming an anti-racist organization, scholarships are prioritized for People of Color and Native people. We will also prioritize scholarship funds for people from other historically marginalized and/or oppressed communities. If you would like to be considered for a scholarship, please complete this form and you will be contacted with a discount code to use at our registration site.

**Scholarship applications are due by March 22, 2017. Decisions regarding scholarship applications will be made by April 5, 2017.**

If you have any questions about scholarships or our process, please contact us at 804.377.0335 or email kpritchard@vsdvalliance.org.

PLEASE DO NOT REGISTER UNTIL YOU RECEIVE YOUR DISCOUNT CODE!

Question Title

* 1. Please complete the information requested below.

Name: *

Organization & Position: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Phone Number: *

Email Address: *

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* 2. This is the first time I've requested a scholarship to attend training from the Action Alliance.

Yes

Question Title

* 3. Do you identify as a member of a historically marginalized and oppressed community?

Yes

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* 4. I have worked in the SV/DV/prevention field for ____ years.

less than 1 year

1-3 years

4-9 years

10-15 years

more than 15 years

If you do not work in the SV/DV/prevention field, please describe your related work and experience.

Question Title

* 5. Please describe how attending the Building Healthy Futures Conference will be beneficial to you in your work to address sexual and domestic violence.

Thank you for completing this scholarship application! An Action Alliance staff member will be in contact with you by April 5, 2017 with a decision.