Susie Ellis Scholarship
for Equity in Wellness Application Form

First name*

Last name*

Pronouns

Job title*

Company name*

Website URL

Date of birth*

Phone number*

WhatsApp Phone Number

Email*

City*

State/Region*

Postal code*

Country (Dropdown)*

How did you hear about the Susie Ellis Scholarship for Equity in Wellness?*

Have you ever applied for the Susie Ellis Scholarship for Equity in Wellness before? If so when? *

Tell us your story. (Which underserved community do you belong to, and how has it influenced your commitment to wellness and equity?)*

Maximum 1000 characters

Why do you deserve the Susie Ellis Scholarship for Equity in Wellness?*

Maximum 1000 characters

What improvements would you like to see in your community in the future? Share two actionable goals.*

Maximum 500 characters

If you become a scholarship recipient, what are your goals at the 2025 Summit and who would you want to meet?*

Maximum 500 characters

We are excited to read through your application. The application deadline is June 30, 2025, and we will announce the scholarship recipients in August.

Susie Ellis Scholarshipfor Equity in Wellness Application Form

Susie Ellis Scholarship
for Equity in Wellness Application Form