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Apply for an Audrey Harris Scholarship today!
Please apply 6 weeks prior to educational event to ensure enough time for the board to review. Thank you for your interest in furthering your neonatal education!
Please complete all * required fields. You must complete ALL FIELDS and submit before navigating away from this page - the form will NOT save your selections and allow you to come back and complete.
Contact Information
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Indicates required field
Name
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First
Last
Address
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Line 1
Line 2
City
State
Zip Code
Country
Phone Number
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Email
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Place of Employment
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Title
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Please list references:
Reference #1 Name
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First
Last
Reference #1 Phone
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Reference #2 Name
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First
Last
Reference #2 Phone
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Reference #3 Name
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First
Last
Reference #3 Phone
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Event Details
Name
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Date (mm-dd-yyyy)
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Location (City, ST)
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Are you willing to share a room with another event attendee?
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Choose One
Yes
No
Event Cost
Registration Cost
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Est Travel Cost
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Est Lodging Cost
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Will your employer be covering any of the cost?
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Choose One
Yes
No
Please explain in 250 words why we should approve your request. Please include:
-History of NICU experience
-Area of special interest in neonatology
-Why you want to attend the event and what you hope to gain
-Your plan to implement what you learn in your NICU
Support your request:
*
Upload Resume
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Max file size: 20MB
Submit Application
