NHF and MyNHPCO Conference Scholarship Application Name:* Organization:* Job Title:* Organization Street Address:* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Which of the following two 2023 NHPCO conferences are you seeking a scholarship for?*2023 Virtual Interdisciplinary Conference2023 Annual Leadership ConferenceBothNHPCO Membership Status*MemberNon-MemberAre you a member of a MyNHPCO Steering Committee?*YesNoMyNHPCO Steering Committee?*Bereavement Professional Steering CommitteeCEO/Executive Director Steering CommitteeCertified Nursing Assistant Steering CommitteeClinical and Operations Management Steering CommitteeDevelopment/Public Relations/Marketing Steering CommitteeProfessional Education and Organizational Development Steering CommitteeFinance/Information Systems Steering CommitteeIntegrative & Rehabilitation Therapies Steering CommitteeNurse Steering CommitteePharmacist Steering CommitteePhysician/Advanced Practice Provider Steering CommitteeQuality Assessment/Performance Improvement Steering CommitteeSocial Worker Steering CommitteeSpiritual Caregiver Steering CommitteeVolunteer Management Steering CommitteeHow long have you served on this steering committee?* Please describe your recent involvement with the steering committee. (e.g. hosting chats, mentor, monitor discussion board)*What NHPCO conferences have you attended in the past 3 years?* 2022 Virtual Interdisciplinary Conference 2022 Leadership and Advocacy Conference 2021 Virtual Interdisciplinary Conference 2021 Virtual Conference (Summer) 2021 Leadership and Advocacy Conference (Virtual) 2020 Interdisciplinary Conference (Virtual) 2020 Virtual Conference (Summer) None of the above Did you submit a proposal to present at the 2023 Virtual Interdisciplinary Conference or are you planning to submit a proposal for the 2023 Leadership Conference (opening March 2023)?*YesNoWhat is your proposal topic?* What is your organization’s Average Daily Census (ADC)?*Does your organization serve traditionally underserved communities, such as rural areas, urban areas, and communities of color?*YesNoPlease explain:*Please provide a brief statement of financial need*How does attending an NHPCO conference influence your professional development plan and future goals? (500 words or less)*Are you applying for a full scholarship or a reduced scholarship?*FullReducedIs there anything else you want the selection committee(s) to know? I certify that, if selected for a scholarship involving a fund distribution, funding will be used for the cost of air or train travel, ground transportation, non-conference meals, and incidentals related to conference attendance. If selected for a scholarship involving a fund distribution, I agree to provide NHF with conference feedback and an accounting report detailing my expenses following the conference. Please note you will be required to complete a 1099 tax form submitted to NHF if you have not already sent us a detailed accounting report. *In person conferences only. Selected scholars for virtual conferences will receive complimentary registrations. Signature (initials):* Date* MM slash DD slash YYYY CommentsThis field is for validation purposes and should be left unchanged.
