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2021 Annual Conference International Scholarship

Please note the deadline for submission of your application is February 15, 2021.

On Behalf Of Organization

Organization Name *

Phone (Main) *

Email (Main) *

Street Address *

City *

Postal Code *

Country *

State / Province *

Conference Scholarship

Applicant Information

First Name *

Last Name *

Job Title *

Email (Primary)

Phone-WhatsApp *

Organization Address *

City *

Country *

Website (Main)

State *

Organizational Information

Is your organization a registered non-governmental organization? *

Yes

No

Is your organization a Heartbeat affiliate in good standing? *

Yes

No

Please note: Joint Affiliation partners include Pregnancy Help Network, Centro de Ayuda para la Mujer (CAM), Pregnancy Care Canada, Association for Life of Africa (AFLA), Movimento per la Vita (MpV), Be'ad Chaim, Pregnancy Support Services of Asia, Pro Vida, etc.

Please select which best describes your relationship to Heartbeat International: *

The organization is directly affiliated with Heartbeat International

The organization is affiliated through a Joint Affiliation Partner

If directly affiliated with Heartbeat, please provide the year you originally affiliated. If affiliated with a Joint Affiliation Partner, please list which one. *

Have you or anyone from your organization attended a training through a Joint Affiliation Partner? *

Yes

No

If you have attended a training for a joint affiliation partner, please provide the date of the most recent training attended:

What services (alternatives to abortion) does your organization provide? *

Number of Clients Served in the Last Year: *

Number of years applicant has served in current organization: *

Describe the populations served, including types of clients and nature of client needs): *

Number of Active Volunteers: *

Number of Paid Staff: *

Number of Board Members: *

List the main resource, program, or manual that your organization uses for volunteer training: *

List the main resource your organization uses for post-abortion study or groups:: *

If your organization has previously received a Heartbeat scholarship, please describe who and when: *

Do you receive help from your government, local or national? *

Yes

No

Do you receive help from a United States pregnancy help organization? If yes, please provide the name of the center. *

If your organization is connected to a particular denomination, please list here: *

If accepted for a registration scholarship, applicant affirms and/or agrees to the following: Recipient is somewhat fluent in English. Heartbeat events are presented in English and translation is not available. Scholarship recipient is expected to attend Virtual Conference workshops.

Conference Scholarship Agreement *

Yes

No

Please type your name and today's date to sign your application.

Applicant Signature *

Please provide the name and email address of a Reference. Ideally the Reference Signature is a Board Chairman, President, sponsoring agent or other organizational authority over/apart from applicant.

Reference Information: *

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