6th Annual Circle of Harmony
HIV/AIDS WELLNESS CONFERENCE
APRIL 19, 20, 21, & 22, 2004

SCHOLARSHIP APPLICATION

NAME:                                                                                                                                                                

AFFILIATION/ORGANIZATION:                                                                                                                     

ADDRESS:                                                                                                                                                           

DAYTIME TELEPHONE NUMBER:                                                                                                         

EMAIL ADDRESS:                                                                                                       

A limited number of scholarships are available for the Circle of Harmony Conference including the registration fee, lodging and per diem. Travel scholarships are only for New Mexico residents. We would like to suggest that you ask your AIDS services organization for assistance before you apply to the Circle of Harmony for a scholarship. Please check below what kind of financial assistance you are applying for.

REGISTRATION FEE:           

TRAVEL EXPENSE:             Approximately how many miles each way?                                   

(This is only for mileage reimbursement for New Mexico residents outside the Albuquerque area at $.33 per mile, no travel advances)

LODGING:     Monday, April 19       Tuesday, April 20     Wednesday, April 21   

Limited scholarships for lodging include up to three nights hotel room only, double occupancy. NO INCIDENTALS.

Name of person you would like to room with:                                                                                   

Please tell us how you intend to share with your community the information you receive during this conference. Attach additional pages if needed.

RETURN TO:        ALBUQUERQUE AREA INDIAN HEALTH BOARD, INC.
                            2004 Circle of Harmony Conference
                            Attn: Annette Trancosa or Rita Kie
                            5015 Prospect Avenue NE
                            Albuquerque, New Mexico 87110   

NO LATER THAN MARCH 15, 2004