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 Honors and Awards for support.

First Name Last Name E-mail Degree Program Choose onePhDDrPhMPHMHSScMScDOther Are you enrolled in a dual degree? e.g. MPH/MSN Yes No Department Choose oneBiochemistry and Molecular BiologyBiostatisticsEnvironmental Health SciencesEpidemiologyHealth Policy and ManagementHealth, Behavior and SocietyInternational HealthMental HealthMolecular Microbiology and ImmunologyPopulation, Family and Reproductive Health Projected graduation date Advisor’s name Advisor’s E-mail 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.