HYLENE S. DUBLIN SCHOLARSHIP FUND APPLICATION

The Hylene S. Dublin Fund is available to GLGPS members only and assists in defraying the cost of attending GLGPS meetings and conferences. Recipients of this scholarship are expected to volunteer service to GLGPS; volunteer opportunities will be available primarily during conference/training events and may include: assisting in set-up or end-of-day re-set; distributing/collecting CE and evaluation forms; registration table assist, etc. Other opportunities may include brief article submission to the GLGPS newsletter on conference experience, contacting peers regarding GLGPS events, etc. Funds are limited; please apply promptly.

Dublin Form Application

As a current GLGPS member, I wish to apply for support from the Hylene S. Dublin Scholarship Fund to help defray registration costs of the following amount in attending the following GLGPS event:*
Title of Event*
Beginning date of event:*
MM slash DD slash YYYY
End date of event:*
MM slash DD slash YYYY
Name:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Work Phone:
Cell Phone:
Place of Employment/School:
Email:
Have you applied for Professional Development funds from your place of employment?
- Yes
- No
Amount Received:
GLGPS Membership Level:
Amount of Scholarship Requested

Typical scholarship offered is 50% of fee; however, the Scholarship Committee will review all requests and make a determination based on merit.
Please state your reason for the scholarship request:
My preference for scholarship volunteer work:
- Pre-conference set-up
- Registration table assist
- CE and Evaluation form collection
- End of day clean-up
- GLGPS Newsletter article
- Contacting peers about GLGPS events
Please select three; assigned on a first-come, first-served basis.

Deadline: Applications must be received no later than three weeks prior to the scheduled event