Applicant First Name: *

Applicant Last Name: *

Address: *

City: *

State/ Province

Zip Code: *

Country * AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamaBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IislandsCosta RicaCote D’ivoire (Ivory Coast)CroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIraqIrelandIslamic Republic of IranIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, Democratic People’s Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People’s Democratic RepublicLatviaLebanonLesothoLiberiaLibyan Arab JamahiriyaLiechtensteinLithuaniaLuxembourgMacauMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldova, Republic ofMonacoMongoliaMonserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSaint LuciaSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSenegalSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSpainSri LankaSt. HelenaSt. Kitts and NevisSt. Pierre & MiquelonSt. Vincent & the GrenadinesSudanSurinameSvalbard & Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwan, Province of ChinaTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited Kingdom (Great Britain)United States Minor Outlying IslandsUnited States of AmericaUnited States Virgin IslandsUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamWallis & Futuna IslandsWestern SaharaYemenYugoslaviaZaireZambiaZimbabwe

Phone: *

E-mail Address: *

Are you at least 18 years of age? *

What is your gender?

Which of the following best represents your racial or ethnic heritage? (Response NOT Required for Submission) N/ANon-Hispanic, White or Euro-AmericanBlack, Afro-Caribbean, or African AmericanLatino or Hispanic AmericanEast Asian or Asian AmericanSouth Asian or Indian AmericanNative American or Alaskan NativeOtherPrefer Not to Answer

Which best classifies your interest in weight and health? (Response NOT Required for Submission) N/APost-Bariatric Surgery PatientPre-surgical Patient (surgical treatment planned and/or scheduled)Individual who has sought non-surgical treatment (pharmacotherapy, medical weight management, etc.)Individual struggling with weight-related issues and not yet sought treatmentOther

Do you have any medical issues that affect traveling? *

If yes, please explain:

Have you attended a past OAC Convention? *

If yes, which year(s) did you attend?

Have you received an OAC Convention Scholarship in the past? *

If yes, which year(s) were you awarded a scholarship?

Please rate your level of comfort with traveling (1 – Not Comfortable and 5 – Very Comfortable) *

With this scholarship request, are you requesting a grant to cover reimbursement for your airfare or mileage? *

With this scholarship request, are you requesting a grant to cover your hotel stay (up to 3 nights available)? *

If requesting a grant to cover your hotel stay, please indicate the number of nights in need. ZeroOneTwoThree

Are you willing to share your hotel room with a fellow attendee, therefore splitting the cost of the room? *

Convention Scholarships are available to cover the cost of Registration fees. Please indicate the Registration Category in which you are requesting a grant: * I am not requesting a grant to cover my registration cost.One-day Convention Registration (Educational and Training Sessions and Expo Hall Access Only)Full Convention Registration (Educational and Training Sessions, Expo Hall, Tickets to Social Events)

If requesting a grant for a One-day Registration, please indicate which days you would like to attend: N/AFriday OnlySaturday OnlyFriday and Saturday

Please describe your financial need. – 50% of application *

How has obesity personally affected you? (500 words or less) – 35% of application *

Why do you want to attend the 2020 Your Weight Matters Convention & EXPO? (500 words or less) – 15% of application *

By completing this application for an OAC Convention Scholarship, you are affirming that the information provided is accurate and that you meet all eligibility requirements, which include: 18 years of age or older (unless travelling with a parent or legal guardian); have plans to attend the 2020 YWM Convention; are an attendee not seeking CE Credits; are not a relative of an OAC staff person, OAC National Board Member, or OAC Committee Member (or actual member of these groups). If awarded a scholarship, recipients may be asked to submit a testimony of their Convention experience (pre or post-meeting) to be used in future promotional materials for the OAC Convention Scholarship Program. Convention Scholarships have a maximum value of $1,350 ($350 – Full Convention Registration actual attendee cost; $500 – Hotel; Up to $500 – Airfare or mileage reimbursement). Convention Scholarships do not have a cash value.
I Agree. *

* Required