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New Hampshire 2024 Community Health Worker Summit Scholarship/Reduced Fee Request Form
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1.
What is your name?
(Required.)
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2.
Please provide your email.
(Required.)
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3.
Do you live and/or work in New Hampshire?
(Required.)
Yes
No (if the answer is no to this question, you do not qualify to receive a scholarship or reduced fees)
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4.
What organization are you affiliated with?
(Required.)
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5.
Please provide your job title and a brief description of your role.
(Required.)
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6.
What area of NH do you serve?
(Required.)
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7.
Why are you interested in attending the NH CHW Summit?
(Required.)
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8.
Why are you requesting a reduced registration fee?
(Required.)
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9.
We are pleased to offer a reduced registration fee of $25 for CHWs to attend the 2024 NH CHW Summit. Can your organization sponsor the $25 registration for you to attend the summit?
(Required.)
Yes, my organization can contribute $25 towards my registration for the NH CHW Summit.
No, unfortunately my organization is unable to contribute any funds towards the registration cost this year.
If the answer is no, please contact Maddie Bailey, Community Health Worker Marketing & Events Coordinator at mbailey@nchcnh.org to request scholarship assistance.