Application for conference fund support

* Note:  You will receive an automatic e-mail verifying that your application was received shortly after hitting 'submit'.  If you do not receive this e-mail within 24 hours of submission then your application was NOT received!  Try again (you may want to use a different internet browser or computer), or if you have any other questions or problems with the form, please e-mail the Student Assembly VP for Communications for support.

First Name «
Last Name «
email «
Degree Program «	-- Select from the following -- PhD DrPh MPH MHS ScM ScD Other
Are you enrolled in a dual degree? « e.g. MPH/MSN	[ Yes ] [ No ]
Department «	-- Select from the following -- Biochem. Biostat. HBS HPM IH Epi. MH MMI Pop. Fam. MPH-customized MPH-concentrating EHS
Projected graduation date «
Advisor’s name «
Advisor’s email «
Have you ever attended a professional conference related to the field of public health before? «	[ Yes ] [ No ]
Name of conference applying for: «
First day of conference «
Website for conference: «
Registration fee amount: « Only student rate and/or early registration rate will be considered if available. If your conference has not yet posted the registration fees, you should enter $500 as the fee and select "no" for the next question.
Has your conference posted the registration fees?	[ Yes ] [ No ]
Have you (or will you) submit an abstract to this conference? «	[ Yes ] [ No ]
Have you been chosen to present your work at this conference? « Answer ‘no’ if notifications have not yet been sent for this conference.	[ Yes ] [ No ]
"I authorize the representatives of the Student Assembly to verify my enrollment status with the Office of Records and Registration" «	[ Yes ] [ No ]
In ONE SENTENCE, tell us how this conference is related to the field of public health? «
In ONE SENTENCE, tell us how this conference is related to your work as a student or your future career plans. « Selection is done *randomly* not by the length or quality of your answers. However, we need to confirm that the conference is related to public health and to your work/career plans.
"I certify that all information given on this application is true and accurate, and I understand that any information found to be false or misleading will result in the forfeiture of any awards granted" «	[ Yes ] [ No ]
Fields marked with "«" are required.