Annual Conference Scholarship Form

Please complete the following questions to apply for a Conference Scholarship. All questions must be answered. For those that do not apply to you, write "N/A."

Your Full Name:

Telephone Number:

Email:

Fiscal Intermediary:

Do you work for a Fiscal Intermediary?

YesNo

Are you a Consumer or Designated Representative?

ConsumerDesignated Representative

How long have you been using CDPA?

Where will you be traveling from?

9.) Please indicate your scholarship needs (Check One):

Conference RegistrationHotelBoth

If your scholarship need cannot be 100% met, are you still interested?

Why is it important for you to attend the 16th Annual Conference?

What issues affecting CDPA are of greatest importance to you and why?

Please describe your history with advocacy and activism related to CDPA:

What previous involvement do you have, if any, with CDPAANYS?

Please list and describe any CDPA-related advocacy events and/or activities you have attended and/or participated in:

Please list and describe any additional activities you believe are relevant to this scholarship application (community groups, committees, boards, etc):

What do you hope to learn from the conference, and how will you apply this knowledge in the future?