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SHSMD Bytes Virtual Conference Scholarship Request
Scholarship priority will be given to
SHSMD
members.
Please complete this form no later than October 13.
The Scholarship Program is generously sponsored by
Prairie Dog
.
*
1.
Contact Information
(Required.)
Name
*
Organization
*
Title
*
City/Town
*
State/Province
*
ZIP/Postal Code
Country
Email Address
*
*
2.
Are you a member of SHSMD?
(Required.)
Yes
No
*
3.
Organization type, please select all that apply.
(Required.)
Academic Medical Center
Critical Access Hospital
Health System
Rural Hospital or Health System
Standalone Hospital
Other (please specify)
*
4.
Briefly describe your role and experience
(Required.)
*
5.
Describe your financial need.
(Required.)
*
6.
How will attendance benefit you and what part of the curriculum has special relevance for your work?
(Required.)
7.
Additional comments
Thank you, your request will be reviewed and processed. Those receiving scholarships will be notified
by October 20.
