The Kansas Rural Health Options Project is providing a limited number of $1,000 scholarships for rural physicians and mid levels to participate in the Advanced Trauma Life Support course. These scholarships will be provided to qualified applicants on a first-come, first-serve basis. It is expected that the scholarships will be used prior to December 31, 2010. Interested individuals should submit a formal letter of request that includes the applicant's name, credentials, license number, and the ATLS Scholarship Request Form (below) to Chad Austin, Vice President, Government Relations; Kansas Hospital Association; 215 SE 8th Avenue; Topeka KS 66603. For further information contact Debbie Hall at the KHA office, (785) 233-7436.
Please complete the following information.
Credentials (circle one)
ARNP PA DO MD
Provider Name: __________________________________________________
Provider Organization: ____________________________________________
Organization Mailing Address (city & zip): ______________________________
Phone: _________________________
Email: __________________________
In which Regional Trauma Council area do you provide services? (Circle all that apply)
NERTC NCRTC NWRTC
SERTC SCKTR SWRTC
Please provide the following information for the ATLS class you plan to attend.
ATLS Course Location: ______________________________
ATLS Course Date: _________________________________
Registration cost: $___________
Have you registered for the course? Yes No
If you need additional funding, please list. Reimbursement will be at the state rate.
Travel (miles)
Lodging
If you are in a residency program, after completion of the program, do you plan on working in Kansas? Yes No
Note: If you are a recipient of the scholarship, you will be required to submit a certificate of completion.
Note: This application must be fully completed to receive a scholarship.
Contact: Debbie Hall