Name
*
Address
*
Phone
*
E-mail Address:
*
Hospital
*
WSHHRA Member?
*
Yes
No
Application for?
*
Spring Conference Registration
Fall Conference Registration
Hotel
Amount Requested
*
Reason for Request (please describe a brief statement regarding your need for the scholarship):
*
Certification of Accuracy: I hereby certify that the information contained in this application is true and correct to the best of my knowledge. I further certify that my employer will not be reimbursing me for these costs.
*
I Certify Information is accurate.
Date
*
*
Required
Scholarship Application