Thank you for your interest in applying for the Nicholas Skala Health Activist Fund Scholarship to attend the Leadership Training and Annual Meeting in Washington, D.C., October 28-29.

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Please fill out this brief application to be eligible to receive up to $100 in funding to cover travel expenses in addition to bus transportation with like-minded students from the New York area.
We will notify you within two weeks of receipt of your application. For questions please write laurie@pnhpnymetro.org or call (212) 485-6235.

First and last name *

Phone number *

Email address *

Medical School *

Medical Specialty *

Desired Medical Specialty *

Expected year of graduation *

Mailing address *

Are you presently involved with PNHP? *

Check all that apply

I'm interested in getting more involved

I've attended a PNHP event

I'm a PNHP member

I'm active locally

Other:

Required

What do you hope to gain by attending the PNHP Annual Meeting? *

Please be detailed in 300 words or less

Why is single-payer health care an issue you care about? *

Please be detailed in 300 words or less

How much funding do you anticipate needing to attend the Annual Meeting? *

Up to $100 in scholarship funding is available for NY-Metro students. Transportation will be arranged through NY-Metro for free.

Please describe your lodging plans *

I would like to stay with other students at the hotel at no additional cost

I will make my own lodging arrangements

Other:

Which events do you hope to attend? *

Please check all that apply

PNHP's Annual Meeting and Dinner on Saturday, Oct. 29

PNHP's Leadership Training and Dinner on Friday, Oct. 28

Other:

Required

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