IM4US Financial Aid/Volunteer Application Form--2019 Conference
Email address *
Your Info
First Name *
Your answer
Last Name *
Your answer
Phone Number *
Your answer
Academic Institution or Employer Name *
List the name of your organization if employed, or the name of the school you attend. If neither apply, enter N/A.
Your answer
Student Type or Professional Title *
List your job title if employed, or the name of the degree program if you're a currently-enrolled student. If neither apply, enter N/A.
Your answer
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Profession *
Required
Household Income *
What is your approximate household yearly income?
Household Size *
How many people are in your household?
Gender *
Race/Ethnicity *
Required
Languages *
What languages do you speak?
Your answer
Work Setting *
Required
Work Environment *
Required
Type of Underserved *
In what way are your clients underserved? Check all that apply.
Required
Providers in Work Setting *
What type of providers are in your work setting?
Required
Your Role *
Describe your role in health care. Check all that apply.
Required
Presenter *
Are you giving a talk or poster at this conference?
Financial Aid/Volunteer Info
Referral *
How did you hear about this volunteer opportunity?
Your answer
Volunteer Interest *
Why are you interested in volunteering?
Financial Aid Request *
What type of aid are you requesting?
My Contribution (Optional)
How much can you contribute to your registration fees, if anything? Enter numbers only.
Your answer
Days You'd Like to Volunteer *
Please let us know which days you would like to volunteer in exchange for financial aid. Please remember you are welcomed to attend the conference before or after your shift.
Required
Availability *
Required
Skills *
I can offer the following skills
Ideal Placement *
Do you thrive better in people-facing or behind-the-scenes roles?
Statement of Need *
Why is it important to receive financial assistance? (750 characters max)
Your answer
Statement of Interest *
Why are you interested in volunteering and attending the conference? (750 characters max)
Your answer
Goals *
What do you hope to gain as a result of volunteering at the conference? (750 characters max)
Your answer
Additional Info (Optional)
Is there anything else you think we should know about you? (750 characters max)
Your answer
Membership *
Are you an IM4US member?
Mailing List *
Would you like to be added to our mailing list?
Next Steps
The deadline for submitting the application is Monday, June 3rd and we will begin responding to applicants the last 2 weeks of June. If you do not hear from us by June 30th, please email info@im4us.org.
Thank you for completing the Volunteer Application!
A copy of your responses will be emailed to the address you provided.
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