2018 Registration Booklet

Scholarship Application continued:
If you are interested in attending Unity Through Diversity: The Power Of Unity, The National Lesbian, Gay, Bisexual
and Transgender People of Color Health Conference in Albany, NY on a scholarship, please complete and submit
the required information by: July 31, 2018. A limited number of partial and full scholarships are available for
individuals who lack the sufficient funds needed to participate. Only one full or partial scholarship will be awarded
per agency based on availability. The determination for scholarship awards will be based on financial need, geographic
distribution, and the transferability of skills gained through attending the Conference to the participants’ respective
agencies and communities. Scholarship winners will be required to volunteer a minimum of 4 hours at the conference.
All information on your scholarship application will be treated with confidentiality. Scholarship recipients will be required
to make their own hotel and travel arrangements. Applications must be postmarked or received by July 31, 2018.
Applications received after the deadline will not be considered. Applicants will be notified of decisions on or before
August 15, 2018.
Send completed scholarship application to:
Mail
In Our Own Voices, Inc.
245 Lark St.
Albany, NY 12210
Email
info@inourownvoices.org
Fax
(518) 432-4123
Name (first, last):_____________________________________________________________ Title:________________________________
Organization:_______________________________________________________________ Web Address:________________________
Address:____________________________________________ City:____________________ State:_____________Zip: _______________
Phone (with area code first): __________________________________________________ Email: _______________________________
Demographic Information. This section is for statistical purposes only. Information provided is optional and confidential.
Sex
__ Male
__ Female
Age
__ Under 20
__ 20-25
__ 26-30
__ 31-40
__ 41-50
__ 50+
Gender Identity
__ Male
__ Female
__ Transgender MTF
__ Transgender FTM
__ Two-Spirited
__ Self-Identify:______________
Sexual Orientation
__ Gay
__ Lesbian
__ Bisexual
__ Questioning
__ Heterosexual
__ Self-Identify:
_______________
Race/Ethnicity
Organization Information
__ African American/ __ Federally Funded Organization
Black
__ State Funded Organization
__ American Indian/ __ State/Local Health Department
Alaskan Native/ __ Community Planning Organization
Native American __ Consultant Organization
__ Asian/Pacific Islander __ Self-Identify:____________________
__ Hispanic/Latin@
__ Caucasian
__ Bi- or MuIti-Racial
__ Self-Identify: ___________________
Scholarship Options: A limited number of partial and full scholarships are available. Choose the scholarship type
that best suits your need. *Note: If chosen for a partial scholarship, recipient will be responsible to pay the costs
associated with the expenses not covered under the scholarship. Please select only one:
13
Scholarship Type:
__ Full
__ Partial - Lodging
__ Partial - Travel
__ Partial - Registration
__ Combination #1
__ Combination #2
__ Combination #3
Includes:
ALL hotel, travel, and registration expenses (up to $1,000)
ONLY hotel expenses (up to $575)
ONLY travel expenses (up to $200)
ONLY registration expenses (up to $295)
ONLY Travel AND Registration expenses (up to $500)
ONLY Lodging AND Registration expenses (up to $875)
ONLY Travel AND Lodging expenses (up to $775)
Not Covered:
Everything is covered
Travel and registration costs
Lodging and registration costs
Travel and lodging costs
Lodging costs
Travel costs
Registration costs