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2017 BDSRA Conference Stipend Application Form
Because of forward-thinking and generous donors who lost their children to Batten disease, each year, there is a limited amount of stipend funding available for families who need assistance to attend the annual BDSRA Conference. Priority is given to families who have not received funding in the past for the conference, new families and those who have been unable to attend for several years due to financial stress. Stipends include one room for up to three nights, and lunch and dinner on Friday and Saturday of the conference. WHO IS ELIGIBLE? 1) Current BDSRA members. 2) Families who have or had a loved one with Batten disease. “Family” is defined as these immediate members: mother, father, guardian/primary care provider and siblings. 3) Costs for adult t-shirts are not included, but can be ordered and paid via the online registration system.
Please complete the form, make sure to sign below and return by April 14, 2017. Requestor’s Name: Address: City:
State:
Telephone: (home)
(cell)
Zip:
Email address: Will you receive financial assistance from a local BDSRA chapter for this conference? Yes
No
If you have received any financial assistance to attend this conference please provide the name of the organization or group and the amount of assistance provided:
Have you attended the BDSRA annual conference before?
Yes
No
Yes
No
If Yes, how many times ? Have you previously received a BDSRA conference stipend? If Yes, how many times ?
Please fill out the following information for 2017 BDSRA Conference Number of nights (maximum of 3 nights):
Number of persons:
Meals are limited to lunch and dinner on Friday and Saturday Parent name:
No. of meals:
Parent name:
No. of meals:
Affected child name:
Age:
Number of meals: Affected child name:
Age:
Number of meals: Sibling name:
Age:
Number of meals: Sibling name:
Age:
Number of meals:
Are there any special circumstances that you would like us to be aware of? ______________________________________________________________________
Signature: Date: Email address:
If you have any questions, please contact Tracy Kirby at 614.973.6013 or
[email protected]. Return form by either mail or fax to: BDSRA, 1175 Dublin Road, Columbus OH 43215 Fax: 866.648.8718
