State Coverage Initiatives National Meeting

**THIS MEETING IS FOR STATE OFFICIALS ONLY **

Travel Scholarship Request Form

The State Coverage Initiatives Program (SCI) has a limited number of travel scholarships available. To help SCI equitably divide resources among deserving requests, please answer the questions below. To be considered for a travel scholarship for the Summer Meeting in San Francisco, submit your request by June 15, 2008. Please limit total response to 2 pages maximum and contact Colin McGlynn at (202) 292-6731, (202) 292-6831 (fax) or email colin.mcglynn@academyhealth.org with any logistical questions.

Title:	Other t
First Name:
Last Name:
Job Title:
State Agency:
Department:
Address:
City:
State:
Zip Code
Telephone:
Fax:
E-Mail:

Do you have an assistant with whom we should be in contact?

Name:
Telephone:
E-mail:

Would you like to be added to our monthly Stateside eNewsletter?
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No
I'm already a subscriber

Special needs (dietary, physical, etc.):

Have you received any SCI travel funds for a prior meeting? If so, please list.

Do you have access to travel funds from a current SCI or HRSA grant?

Would not receiving a scholarship impact your attendance at this meeting?

Have you applied for travel funds from the state?

Please describe your interest in this meeting and how attending this meeting would assist your work with the state.

There is no registration fee for this meeting.