HCIC Scholarship Application

First Name *

Last Name *

Title*

Organization*

City*

State*

Zip*

Phone*

Email*

Which Category Best Describes Your Organization?*

Academic Medical Center
Large Health System
Cancer Center
Medium-Sized Health System
Children’s Hospital
Health Plan
Small Health System
Medical Group Practice
Other

Have you attended a previous HCIC conference?*

Yes
No

If “Yes,” please indicate year(s) attended

2010, 2012, etc.

Have you been involved with HCIC as a/an (Check ALL that apply):*

Speaker for HCIC?
Speaker for a Webinar?
Webinar Attendee?
Attended Let's Talk?

Why do you want to attend HCIC?*

250 words or less

How will HCIC contribute to your professional development?*

250 words or less

Why are you requesting financial assistance to attend HCIC (e.g. budget restrictions, travel freeze, recent job loss, etc.)? If currently employed, please attach signed documentation from your CEO or direct manager that establishes financial need OR a copy of current policy on travel cost restrictions.*

250 words or less

Several of our HCIC scholarship options are sponsored by vendors. Would you be willing to attend a 15-minute webinar demo with a vendor of interest to you in exchange for a scholarship to HCIC?*

Yes
No

Commitment to Attend

Commitment to Attend*

If selected to receive a scholarship to attend HCIC, I hereby certify that I plan to attend. I understand that the scholarship entitles me to attend HCIC and one pre-conference workshop, but does not include my transportation and hotel costs or any other expenses related to my attendance. If selected as a scholarship recipient, I will provide HCIC (via email at info@greystone.net) with a copy of my transportation and hotel confirmation within two weeks of notification of my acceptance.