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Safety Summit Scholarship Application
Thank you for your interest in attending the 2018 Zero Fatalities Safety Summit on April 11-12, 2018 with a pre conference on April 10. There are a limited number of scholarships available to attend the Summit. Complete this form and submit before January 31, 2018.

Use only one form per applicant. If the application is approved, you will receive additional instruction. Please note, scholarships given for registration fees require a code, which must be used when completing the online registration. The code will be provided to approved scholarship applicants. If you have any questions or concerns, email Robyn LaLumia at rlalumia@utah.gov.

ATTENTION UDOT EMPLOYEES: DO NOT fill out the scholarship application, please CONTACT Kristen Hoschouer for scholarship code at khoschouer@utah.gov.

Person Requesting Scholarship *
Please provide the name of the person needing scholarship
Your answer
Agency *
Your answer
Address *
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City, Zip Code *
Your answer
Mobile Phone *
Your answer
Email Address *
Your answer
Primary Area of Interest *
Does your agency receive grant funds from the UHSO? *
If yes please provide title of grant and funding amount:
Your answer
Scholarship Request(s) *
Please select all that apply
Required
If requesting lodging scholarship, please provide your check-in and check-out dates, as well as bed preference (2 Queen or 1 King). State policy: To qualify for lodging, personnel must live at least 100 miles from conference.
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Why are you requesting assistance to attend the Summit? *
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Briefly describe what activities you engage in to promote traffic safety. *
Your answer
Briefly describe how you plan to use the information and resources gained from attending the Summit. *
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