KCNQ2 Cure Summit Scholarship Application

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Application for the 2020 KCNQ2 Cure Summit Scholarship program

Email *

First Name *

Last Name *

Full Address *

Have you previously received a scholarship to attend the KCNQ2 Cure Summit? *

Yes

Have you applied for funding from other resources for the Summit? You can find a list of funding resources under the "Resource" tab on the Summit registration page. *

Yes

If "Yes", from where?

Scholarship Types

Four levels of scholarships are available:

Gold Level:
- Up to $500 per person for roundtrip economy airfare (up to four family members)
- Registration fees covered (up to four family members)

Purple Level:
- Registration fees covered (up to four family members)
- Two nights of hotel accommodations at the conference hotel

Blue Level:
- Two nights of hotel accommodation at the conference hotel

Green Level:
- Registration fees covered (for up to four family members)
* No other travel reimbursement/stipends will be provided

What's not covered in the scholarship:
- airport transfers
- parking
- checked bags
- meals not directly associated with the conference
- additional nights at the hotel above the those offered above
- hotel incidentals

Which scholarship are you applying for? *

Gold

Purple

Blue

Green

Family *

Please list the first and last names of additional family members who will be attending the Summit with you . Include the ages of any children, as well as whether or not they have KCNQ2.

Which days do you plan to attend the Summit (check all that apply) *

Friday

Saturday

Sunday

Required

Please let us know a little bit about your financial situation and why the reviewers should consider awarding a scholarship to you. *

Please let us know your involvement in the KCNQ2 community and why attending the KCNQ2 Summit is important to you. This should be written in essay form and should be 500 words or less. *

If you need more essay space....

Send me a copy of my responses.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of KCNQ2 Cure Alliance. Report Abuse

Forms