The First National Conference on Precaution
June 9th – 11th, 2006
University of Maryland School of Nursing, Baltimore MD
SCHOLARSHIP APPLICATION
DEADLINE: Receive by Friday, April 14, 2006
Name:
Organizational Affiliation (if any):
Are you a volunteer ( ) or a staff person ( ) for your organization? Check one.
Address:
Phone (H or W ):
E-mail:
1) Briefly describe the issues that you or your organization is working on, and the
geographic area addressed.
2) Briefly list the constituencies you or your organization work with.
3) How would participation in the conference benefit you or your group's work?
4) Briefly describe why you or your organization request financial assistance to attend
the conference.
5) We are providing partial scholarships in most cases in order to stretch our
funds and assist as many people as possible. Therefore, we ask that you
cover some of your expenses.
Please place an "X" next to the items that you are requesting support for, and
please list the estimated expense.
$200 Registration Fee (Fee includes: Lunches (3) Friday, Saturday, Sunday;
Dinner on Saturday; Refreshment Breaks; Friday Reception; Conference
Resource Packet, including book.)
$
Hotel Room (share with roommate) for Thurs__ Fri__ Sat__ nights.
(Approximately $75/night with roommate.)
$
Travel Expenses. Please estimate expense based on discount travel
service for: airfare, train, bus, or mileage if driving. Circle the form of
transportation you would be using.
$
Total Scholarship Requested
Date Submitted:_____________________________________________________
Please feel free to provide any additional information that you think we should know.
Support will be prioritized where financial need can be demonstrated.
Submit Application: Please mail, email or fax to CHEJ, PP Conf. Scholarship, P.O.
Box 6806, Falls Church, VA 22040-6806, FAX: 703-237-8389, ppconference@chej.org,
The application must be received by Friday, April 14, 2006. Thank you.
Notification: You will be notified by May 1st about the decision.
* If you receive an air travel scholarship, it is contingent on making a reservation in time
to receive a 30-day discount (by May 8th).
* If you receive a scholarship, you will be asked to do one volunteer task (approximately
2 - 3 hours of your time) at some point during the three-day event.