Bursary Application | Arthritis Health Professions Association

First Name *

Last Name *

Address *

City *

Province *

Postal Code *

Institution *

Work Number

Fax Number

Email *

Preferred Language *

Discipline Within Rheumatology *

If Other

Primary Rheumatologist You Work With *

Why attending the pre-course would benefit you? *

Have you been given funding to attend the AHPA pre-course in the last two years? *

Yes No

I will be receiving or have applied to other funding sources / agencies / pharma co. or my employer for funding or re-reimbursement for the CRA-AHPA conference registration fees or for travel/accommodation. *

Yes No

I agree the information provided is true and accurate. *

I agree to submit proof of registration for the CRA-AHPA conference, including registration for the AHPA Annual General Meeting, by email to the AHPA within 5 business days of receipt of confirmation of a successful bursary award. Email connect@ahpa.ca with proof of registration. *

I understand that failure to provide proof of registration within 5 business days of being awarded a bursary will result in forfeiture of the bursary award. *

I agree that failure to attend the AHPA Pre-Course AND the AHPA Annual General meeting will result in forfeiture of the bursary award and that no refunds for conference fees will be issued. *