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CME Conference Scholarship Application
Contact Details
Name
(Required)
First
Last
Preferred Pronouns
Do you want this to be included on your name tag?
Yes
No
Job Title/Profession/Credentials
To include on your certificate
Email
(Required)
Enter Email
Confirm Email
Phone
(Required)
Your Location
(Required)
City
State / Province / Region
Please include a statement on what you hope to learn at the conference and what you will bring back to your communities.
(Required)
We strongly encourage participants from BIPOC, LGBTQ+ and other diverse identities to consider applying for these scholarships. Applications are due May 15, 2023.
How did you hear about this event?
Social Media
Google
Word of Mouth
Refer a Friend
Past Participant
Other
Dietary Restrictions?
Will you be attending the Free Evening Dinner Educational Presentation sponsored by Jada?
Yes
No