Application for Conference Scholarship (registration only)

The Florida Department of Children and Families is sponsoring up to 55 individuals to attend the conference. This sponsorship is contingent on funding availability.

Please complete the following form and indicate the reason for your request. Only one individual per agency can receive a scholarship. The deadline to apply for scholarships is Friday, September 18, 2009 at 5:00 pm. This form is an application for scholarships only. You will be officially registered for the conference after acceptance of the scholarship.

All scholarship requests will be reviewed and you will be contacted within 5 business days of receipt of your application. If your request is approved, you will be sent a letter via email to confirm acceptance. If you have any questions, please forward them to Freyja Harris at freyja@fchonline.org or 850-412-0021 or Lavonia Sampson-Jones at admin@flshc.net or 850-878-2196.

Fields marked with * are required.

Title:
First Name:	*
Last Name:	*
Agency:	*
Address:
City:
State:
Zip Code:
Email Address:	*
Phone:
Fax:
Brief reason for scholarship request (100 words or fewer): Please indicate if you have received a scholarship for this conference in the past.* Yes No