Florida Academy

of Nutrition and Dietetics

Public Policy Workshop Stipend Application Form

(*)First Name: Please enter your first name. Middle Initial: (*) Last Name: Please enter your last name.
(*) AND Number:
Please enter your ADA member number.
(*) Address Line 1:

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Address Line 2:

(*) City: Please enter the city. (*)State: must contain only A-Z characters (*)Zip Code: Please enter your Zip code. +4:
(*) Email: Please enter a valid e-mail address. (*)Telephone: Please enter a contact number.
(*)I am applying for the following stipend: Public Policy Workshop Stipend
(*) Event Start Date:

Please select an event start date.
(*) Event End Date:

Please select an event end date.
(*) Cost to attend; include proposed expenses:

Please enter a numeric amount.
Have you ever attended this event before?Invalid Input
(*) Why is public policy important to the future of dietetics?

Please answer this question.
(*) List at least three (3) objectives for participating in this experience:

Please explain.
(*) Explain how this opportunity with our legislators and public policy will enhance your dietetic career:

Please explain.
(*) AND member since (year): Please enter the year. (year) (*) Number of years lived in Florida: Please select.
(*) Member of FAND since (year): Please enter value. (year) (*) Member of District: Please select your member district.(*)Since: Please enter a year. (year)

Florida Academy of Nutrition and Dietetics

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