Scholarship Application

First Name of Contact Person*
Last Name of Contact Person*
Password*
Confirm Password*
Email for Contact Person*
Phone number*
Institution/organization*
Preferred Gender Pronouns*
Eligibility Criteria - please check all that apply.*







Do you wish to apply for a REGISTRATION scholarship?*
Mailing Address*
If you live 100 miles or more away from Atlanta, GA, do you wish to apply for a LODGING scholarship?*
Did you submit an abstract for presentation (oral or poster) for the 2019 National LGBTQ Health Conference? *
Please upload a pdf of your current resume or CV.*
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Please upload a pdf of a letter of recommendation (on letterhead) from a supervisor or academic reference.*
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Please tell us how attending this conference will impact your future career goals (250 words or less). *(Up to 250 Words)
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