AHA Navigating a New Reality Virtual Conference Scholarship Request

Scholarship priority will be given to applicants of hospitals and health systems of the American Hospital Association and members of SHSMD.

Please complete this form no later than August 25, 2020. UPDATE - DEADLINE EXTENDED TO SEPTEMBER 7, 2020

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* 1. Contact Information

Name *

Organization *

Title *

City/Town *

State/Province *

ZIP/Postal Code

Country

Email Address *

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* 2. Organization type, please select all that apply.

Academic Medical Center

Critical Access Hospital

Health System

Rural Hospital or Health System

Standalone Hospital

Other (please specify)

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* 3. Briefly describe your role and experience

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* 4. Describe your financial need.

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* 5. How will attendance benefit you and what part of the curriculum has special relevance for your work?

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* 6. Additional comments

Thank you, your request will be reviewed and processed. Those receiving scholarships will be notified by September 4.