Scholarship Application
Please fill out the following form to be considered for the partial scholarship for one the courses offered on The Lactation OT platform. We review applications on a monthly basis.
Email *
Name (Last, First) *
How do you racially identify? *
Please indicate your preferred pronouns. *
Profession (include state and license number) *
ex. OT in CA #111111
How long have you been practicing within your profession? *
Which course are you most interested in? (1st choice) *
Please check the course website to ensure that the course requesting is available for your profession.
Which course are you most interested in? (2nd choice) *
Please check the course website to ensure that the course requesting is available for your profession.
What are your professional goals? What steps have you currently taken to meet your goals? *
If applying for a need based scholarship. Please fully explain any extenuating circumstances. Write N/A if not applying for need based scholarship. *
By typing my name below, I certify that the information on this application is correct and complete. I understand that if I am awarded a scholarship and do not use it within 30 days, I forfeit it. I would therefore have to reapply and this will be based on availability. By accepting this scholarship, I pledge my commitment to complete the course. *
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of The Lactation OT.

Does this form look suspicious? Report

Google Forms