Diabetes Update Scholarship Form

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We recognize that many people have been impacted by COVID 19 and may not be able to afford the registration fee to attend this year's Diabetes Update. This year we are offering ten scholarships for those who otherwise would not be able to participate.

Requests will be considered on a first come, first serve basis. In order to be to considered for this scholarship, this form must be received no later than February 26, 2021. No requests will be considered after this date.

Scholarships will be given according to the following criteria:

Ten (10) healthcare and public health professionals who address prevention, diagnosis and treatment of diabetes and/or obesity, including physicians, physician assistants, nurses, dietitians, certified diabetes educators, social workers, students, residents, fellows and others involved in diabetes and obesity care on a local, regional, or national level.

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* 1. Address

Name

Organization

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 2. Reason for scholarship request:

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* 3. How would you characterize your organization?

Public/Government

Educational Institution

For-Profit

Non-Profit/501c3

Community Coalition

Grassroots Advocacy

Other (please specify)