CRTAC Scholarship Request - Rocky Mountain Rural Trauma Symposium

Application must be made by individual requesting to attend.

*Maximum 3 scholarships per facility or agency are available. If selected, you will be notified by email with instructions on how to proceed. In the event that there are no more scholarships available for your facility, you will be added to a waitlist in the order of application receipt.

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* 1. Contact Information

Name

Facility or Agency

Profession / Discipline

City

State

Email Address

Phone Number

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* 2. In a few words, describe why you are requesting this scholarship.

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* 3. If awarded a scholarship, I agree to attend the conference and will not share the discount code provided.

Agree

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* 4. I understand that the scholarship is for registration fees only. I am responsible for all other costs associated with attending the conference.

Agree