IM4US Financial Aid/Volunteer Application Form--2019 Conference
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.
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.
Advocate/Community Health Worker/Promotora
Health Care Provider
What is your approximate household yearly income?
less than $25,000
greater than $100,000
Prefer not to state
How many people are in your household?
6 or more
Prefer not to say
Native American/Alaska Native
Prefer Not to State
What languages do you speak?
Public Health/FQHC/Nonprofit health care setting
Type of Underserved
In what way are your clients underserved? Check all that apply.
Poor access to care
People of color
Discrimination due to: sexual orientation, gender, language, religion, culture, disability, etc.
Providers in Work Setting
What type of providers are in your work setting?
Conventional providers (CNM, NP, MD, etc.)
Integrative providers (blend conventional and alternative treatments)
Complementary/Alternative providers (Acupuncturist/TCM, chiropractor, naturopath, herbalist, etc.)
Describe your role in health care. Check all that apply.
Part time provider
Full time provider
Provide integrative care
Provide conventional care only at this time
I do not provide clinical care
Have been in health care <5 years
Have been in health care 5- 10 years
Have been in health care > 10 years
Are you giving a talk or poster at this conference?
Financial Aid/Volunteer Info
How did you hear about this volunteer opportunity?
Why are you interested in volunteering?
Volunteering in exchange for registration support
Volunteering for academic credit
Volunteering to help IM4US
Financial Aid Request
What type of aid are you requesting?
Partial waiver of registration fees (I am aware of and unable to pay the Reduced Rates: 1 day: $175; 2 days: $250; 3 days: $375)
Full waiver of registration fees
Not requesting aid--only want to volunteer
My Contribution (Optional)
How much can you contribute to your registration fees, if anything? Enter numbers only.
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.
Days or weeks leading up to the conference
Wednesday, 8/21 1-5:00 pm
Thursday, 8/22 AM
Thursday, 8/22 PM
Friday, 8/23 AM
Friday, 8/23 PM
Saturday, 8/24 AM
Saturday, 8/24 PM
I can offer the following skills
A/V tech support (only basic support needed, such as helping presenters with slides)
Graphic design (and have access to design software)
Photography (and have own camera)
Videography (and have own camera)
Whatever is needed
Do you thrive better in people-facing or behind-the-scenes roles?
Behind the scenes
Either is okay
Statement of Need
Why is it important to receive financial assistance? (750 characters max)
Statement of Interest
Why are you interested in volunteering and attending the conference? (750 characters max)
What do you hope to gain as a result of volunteering at the conference? (750 characters max)
Additional Info (Optional)
Is there anything else you think we should know about you? (750 characters max)
Are you an IM4US member?
No, but I am interested in joining (go to
Would you like to be added to our mailing list?
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
Thank you for completing the Volunteer Application!
A copy of your responses will be emailed to the address you provided.
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