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Diabetes Coalition of Palm Beach County
Home
About Us
Our Story, Mission & Vision
Diabetes Coalition Initiatives
The Alarming Impact of Diabetes
Strategic Plan
By-laws
Our Leadership Team – Board of Directors
Volunteer
Data
Resources
Why Join?
Why Join?
New Member – Renewal Application
Pay Annual Membership Dues
Member Scholarship Application
Committees – Opportunities to Contribute
Events
Event Calendar
Know Your Numbers Diabetes Prevention Screening Campaign (Featured Event)
Diabetes Awareness Day
(Featured Event)
Past Event Highlights
Sponsors
Join Our Cause
Thank You To Our Funders & Sponsoring Partners
Become A Donor
Know Your Numbers Sponsor Form
A Tribue To Barbara Jacobowitz
Donate
Home
About Us
Our Story, Mission & Vision
Diabetes Coalition Initiatives
The Alarming Impact of Diabetes
Strategic Plan
By-laws
Our Leadership Team – Board of Directors
Volunteer
Data
Resources
Why Join?
Why Join?
New Member – Renewal Application
Pay Annual Membership Dues
Member Scholarship Application
Committees – Opportunities to Contribute
Events
Event Calendar
Know Your Numbers Diabetes Prevention Screening Campaign (Featured Event)
Diabetes Awareness Day
(Featured Event)
Past Event Highlights
Sponsors
Join Our Cause
Thank You To Our Funders & Sponsoring Partners
Become A Donor
Know Your Numbers Sponsor Form
A Tribue To Barbara Jacobowitz
Donate
Scholarship Application P 2
Scholarship Application
Date
MM slash DD slash YYYY
Name
*
First
Last
Title & Credentials
Home Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Home Phone
Personal Email
Race/Ethnicity
African American/Black
White
Asian
Native American
Hispanic
Other
Are you bilingual?
Yes
No
If yes, what language (s)?
Place of Employment
Job Title
Work Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Work Phone
Work Email
Briefly describe the last 5 years of your employment
Describe specific activities you do to enhance diabetes prevention and/or care
Briefly describe your prior diabetes related education
What percentage of your workweek is spent with diabetic patients?
10%
20%
30%
40%
50%
60%
70% or more
Describe the educational opportunity you wish to receive scholarship for and the cost
How will this education directly benefit the work you are doing to improve diabetes care and help you achieve your professional goals
Please let us know any other compelling reasons why you should be awarded this scholarship
Upload copy of flyer, invoice and/or receipt for educational opportunity
Drop files here or
Select files
Max. file size: 300 MB.
Upload Your Photo (Headshot)
Drop files here or
Select files
Max. file size: 300 MB.
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