2019 Practitioner Workshop - ASTHO Scholarship Application
The Association of State and Territorial Health Officials (ASTHO) will fund two state or territorial health agency staff to attend the 2019 Practitioner Workshop in Minnesota. This application is for anyone wishing to be considered for one of the ASTHO scholarships.

Please note that only U.S. state or territorial health agency staff are eligible to apply. The scholarship will cover the registration fee, 2 nights lodging, air travel, and incidentals.

Complete the following and submit before February 1, 2019. Before completing this form, please register (https://hiasociety.org/event-2964959/Registration) for the workshop (no payment necessary).

Applicant Information
Name *
Your answer
Email *
Your answer
Organization *
Your answer
Title *
Your answer
Phone Number *
Your answer
Why are you interested in attending the 2019 HIA Workshop? What do you hope to share and learn? (100 words or less) *
Your answer
Is your agency working to build HIA or HIAP capacity? If so, how and how will your attendance at this meeting support those efforts? (100 words or less) *
Your answer
Are you presenting at this meeting (not required for scholarship) *
Thank you for your submission! We will inform selected presenters by February 23rd. If you have any questions, concerns, or need to make a modification of your application, please contact Ellen Schwaller (ellen@hiasociety.org). Thanks!
Submit
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service