Women & Power Scholarship Application

Applicant Information
* required fields  
*First Name: *Last Name:
*Address:
*City:
State/Province: Zip/Postal Code:
*Day Phone: Evening Phone:
Cell Phone: Fax:
*Email:
Web Site:
Occupation
Employer:
Organization's Mission:
Income
Individual
*Total Household Gross Annual Income as reported on most recent tax forms: $
*Total number of people in household (as shown on tax forms):
Organization (if applicable)
Total Organization budget: $ Number of Employees:
Optional Information
Gender: Female Male
Age: 18-25 26-34 35-45
  46-59 60-69 70 and over
Ethnicity: American Indian/ Alaskan native Hispanic/ Latino
  Asian/ Pacific Islander White/ Caucasian
  Black/ African American Multi - ethnic
  Other:

Accomodations
* required fields  
I accept the accommodations available for this scholarship.
I do not need accommodations.
My preferred roomate is:
If children will be accompanying you and utilizing the Children's Program (ages 4-12 only), please list them below:
Name: DoB:
Name: DoB:
Name: DoB:
Transportation
Omega runs a charter bus to and from Omega between New York City and the Rhinebeck campus on Fridays and Sundays. If awarded a scholarship, would you utilize this service? ($70 Roundtrip. Please see scholarship details to determine if cost is part of the scholarship.)
YesNo
Special Needs
If you have any special needs, please specify them here
Have you ever recieved an Omega scholarship? YesNo
If so, which workshop(s) or conference(s)?

Personal Short Answer Questions
* required fields  
Please thoughtfully and concisely answer the following questions:
*Why do you want to attend this program?
*How would you share or put to use what you learn at the event in your work, family, or larger community?
Please understand that submitting an application for a scholarship does not register you for the conference. If you receive this scholarship, you must call to accept it. Only then will you be registered for the conference.

I certify that all of the above information is true and that all income is reported. I understand that this information will be kept strictly confidential and is only used in determining scholarship eligibility.