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HCIC Scholarship Application

This Scholarship is Proudly Sponsored by:

Deadline for Submission: August 30, 2024

First Name *

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Last Name *

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Title*

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Organization*

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Address*

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City*

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State*

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Zip*

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Phone*

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Email*

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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

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Have you attended a previous HCIC conference?*

Yes
No

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

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2018, 2022, etc.

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

Speaker for HCIC?
Speaker for a Webinar?
Webinar Attendee?

Why do you want to attend HCIC?*

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250 words or less

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How will HCIC contribute to your professional development?*

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250 words or less

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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.*

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250 words or less

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Upload Documentation

Terms of Agreement

Agree to Terms*

By applying for a 2024 HCIC Scholarship, the applicant consents to the submission of their information to Reason One and HCIC. The applicant acknowledges that Reason One and HCIC may contact them in the future for marketing and other related purposes.

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2951 Flowers Road South, Suite 230 • Atlanta, GA 30341
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