Travel Assistance Scholarship Application
The KCNT1 Epilepsy Foundation has a limited number of partial scholarships available to assist KCNT1-affected individuals and families who might otherwise not be able to attend the 2024 Conference at Children's Hospital of Philadelphia and Million Dollar Bike Ride. 

The number of scholarships awarded is dependent on the number of applicants and the amount of sponsorship funding that the KCNT1 Epilepsy Foundation receives for the Conference. It is our hope to award scholarships to as many families as possible, and therefore the amount for each will be limited to a maximum of $500 per family. 

Scholarship awards are not intended to cover your entire cost to attend. Funds are available to cover the cost of hotel accommodations at the Conference hotel and conference registration fees only. Travel expenses are not eligible and must be covered by the recipient.

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Email *
First Name *
Last Name *
Street address *
City *
State/Province *
Postal Code *
Country *
How many KCNT1-affected individuals are in your immediate family? *
How many individuals in your immediate family will be attending the conference? *
Please provide a brief description of what you hope to gain from attending the Conference.
 *
Please select how the scholarship would be used (you may select more than one).
 *
Required

What is the total amount of assistance you are seeking from the KCNT1 Epilepsy Foundation? You can request a maximum of $500

 *
Do you agree to the following terms: (i) I understand that completing and submitting this application does not guarantee scholarship funding; (ii) if I/we do not ultimately attend the 2024 Conference in Philadelphia, any scholarship awarded will be forfeit; (iii) I commit to active participation in the Conference, which includes attending all educational sessions, participating in a parent panel discussion, completion of a post-Conference survey and submission of a description of the impact the 2024 Conference had on yourself/family.
 *
E-signature  *
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