Chronic Disease Scholarship Form

Scholarship Request Form

A limited amount of scholarship money is available for the 2015 Arkansas Chronic Disease Forum so requests will be considered on a first come, first serve basis.

Scholarships may be used toward the registration fee ($50). In order to be considered for a Forum Scholarship, this form must be received no later than April 17th. No requests will be considered after this date.

Scholarships will be given according to the following criteria:
Five (5) community advocates from non-profits and coalition members
unaffiliated with state,federal or local agencies, and

Five (5) students from the UAMS School of Nursing, School of Pharmacy,
College of Public Health and Clinton School of Public Policy and those
involved in Heart-to-Heart Sweethearts.

Scholarship awardees will be expected to assist event organizers before and after the forum.

Question Title

* 1. Please enter your information:

Participant Name:

Organization Name:

Address:

City/Town:

State:

ZIP:

Email Address:

Phone Number:

Question Title

* 2. Reason for Scholarship request:

Question Title

* 3. How would you characterize your organization?

Public/Government

Educational Institution

For-Profit

Non-Profit/501c3

Community Coalition

Grassroots Advocacy

Other (please specify)