SEYCOHAIDS 2012 JUNE 6-8
Scholarship Application Form
(Scholarship applicants need to fill out regular registration form send it together with the scholarship application form)
Send this completed form to: scholarship@ seyco2012.org
To be considered as a scholarship recipient, this form must be completed and postmarked no later than 25th February 2012. All email applications and faxes must be received by May 1st, 2012.
Scholarships are limited. Scholarships will be issued on the basis of your application. Those who submit an abstracts will have an added advantage to attend the Conference. You will be notified by May 11th 2012 regarding your award.
Please print clearly:
Full Name:______
Mailing Address: ______
City: ______State:______Zip:______Country:______
Day Phone:______Fax:______
Email:______
How did you hear about this conference?
____Direct Mail ____Email ____Local Website ____Word of Mouth ____Other______
Race/Ethnicity:______
(Your response is optional but we are committed to ensuring a diverse group of participants)
Are you ____Male ____Female (this information is needed for matching gender)?
Scholarship Program
SEYCOHAIDS 2012 will give … scholarships to individuals who benefits from attending this international conference but have minimal financial means to attend the conference. Scholarship will be given to special groups such as people living with HIV (PLHIV), students, researchers, media representative, community based organization leaders, etc.
SEYCOHAIDS 2012 will give full or partial scholarship which includes:
Full Scholarship: Free conference pass (600 USD – average cost of registration) to the conference, round trip air ticket (1,500 USD), accommodation and daily subsistence allowance for 3 days (… USD Total)
Partial Scholarship:
· Free registration only, or
· Free registration and round trip air ticket, or
· Free registration and accommodation with daily subsistence allowance
Benefit packages will be designed specifically to the interest of companies or agencies.
I am applying for (check one):
____ Partial Scholarship (Please choose)
____Travel Expenses*
____Room and Board (on-campus housing and meals)
____ Registration Fee
*Upon acceptance, we will notify recipients of the amount we have allotted for their scholarship. Special arrangements can be discussed if it is impossible for participants or their organizations to pay for travel up front.
____ Full Scholarship (travel expenses, housing, meals, and registration)
Special Needs (Dietary, environmental, disability access & needs) please specify:
Please use the space below for a brief bio. This information will be used for the conference participation bio list unless you specify otherwise. (Please type or print clearly)
We ask that you answer the following questions (print clearly).
1) Describe your current work and the community with which you work. Include a description of any community-based research projects you are involved with in your community.
2) What will your participation in the conference bring to the community with which you work?
Please describe your plans for sharing what you learned.
3) Give an example of an experience in your life that has stimulated your interest in this work and your participation in this conference.
4) Explain your need for a scholarship.
5) Please include the names and phone numbers of two references that can speak to your work in the community.
Questions? Call us or email us.
Tel: +265 (0) 1 727 730 Fax: +265 (0) 1 727 730| Email: www.seyco2012.org