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Arizona Rural Women's Health Network. Rural Women's Health Symposium Scholarship Form
****This event is being Rescheduled**** The third Annual Rural Women's Health Symposium will be held on May 2 & 3 at Hon-Dah Resort in Pinetop, Arizona. This scholarship will cover registration fee, hotel stay or both. --If awarded, please advise 72 hours before symposium date if you will not be able to attend. Failure to do so will result in personal liability to pay for missed hotel room rate.--DEADLINE APRIL 12, 2018-- If awarded hotel night, awardee must confirm they will attend. A no show will result in a personal payment. ****This event is being Rescheduled****
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Name: *
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E-mail *
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Phone Number *
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Organization and title/role: *
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What geographic area do you serve? *
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Mailing address *
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Please indicate whether you need a scholarship for registration, accommodations or both: *
Why should we award you a scholarship? *
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If awarded, by submitting this form I will notify my attendance and if unable to attend I will notify 72 hours before the symposium. If there is a no show I will be responsible for payment and I have confirmed the mailing address and contact information listed above is correct. *
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