Scholarship Application – MSDH Employees Only

Name *

First

Last

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Credentials (if applicable)

Name as you like to see it printed on badge

Email *

Phone *

Address *

Address Line 1

City

State

Zip Code

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Scholarship Type *

MSDH Employee Department OR College/University Currently Enrolled? *

T-Shirt Size *

Field of Study (if applicable)

What are your plans for utilizing the conference information to address health in Mississippi? *

Emergency Contact Information

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Name *

Phone *

We appreciate your interest in attending the 2025 Empowering Communities for a Healthy Mississippi Conference and will contact you regarding the status of your application once it is reviewed. In the meantime, if you have any questions, please email info@healthymsconference.com.