Application for Lactation Program Scholarship

Today's Date*
MM slash DD slash YYYY
Name*
First Last
Address*
Street Address City State / Province / Region ZIP / Postal Code
Phone*
Email*
How did you hear about our scholarship?*
Name & Date of program you would like to attend. Include cost, CERPS provided and whether continuing education is required to maintain certification. Please include links or other information to be considered by the WALC Board.*
****Include website link for program
How will this scholarship help you to provide service to breastfeeding families in an underserved Community?*
What skills do you bring to this work and how will this course impact your work?*
Will you receive financial support from another source to attend this program?*
If Yes, how much money is your other source providing:
I understand I need to send documentation showing I have completed the program to the WALC President and if I do not complete the program I agree to repay WALC the scholarship amount.*
- Yes, I understand I need to complete the course or repay the scholarship

WALC