Adult PH Conference Scholarship Application

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Adults living with pulmonary hypertension are welcome to apply to receive $500 to attend PHA's 2022 International PH Conference. Funds may be used to cover travel costs, including airfare, gas, lodging, registration, and meals for adult PH patients to attend the 2022 PH Conference. Before filling out this application, please be sure to carefully read the requirements to be a scholarship recipient below:

-Patient must be 18 years or older
-Funds may only be used to cover conference attendance costs including airfare, gas, lodging, registration, and meals
-Applicants cannot receive financial assistance to attend conference from other entities in order to be a recipient of this fund
-International patients are welcome to apply*
-Applicants must have a PayPal account for disbursement of funds
-Applicants must provide receipt of purchase
-Applicants must agree to allow Team PH to share their name, photo, and PH story to use to in promotions
-Applicants must check in at the Team PH booth at the conference

*International applicants may receive financial assistance from other entities to attend conference.

Please be detailed when filling out the application. If you have any questions, please contact program manager Katie Werner at katie@teamphenomenalhope.org.

Email *

General Information

Patient's First and Last Name *

Patient's Age *

FULL ADDRESS, City, State, Zip *

Phone Number *

Tell us why you would like to attend conference. *

Is a caregiver planning on attending with you? *

Have you and/or your family members attended the PH Conference before? *

Yes

Patient Verification

What is your diagnosis? *

Are you treated by a doctor for pulmonary hypertension? *

Yes

At what medical center are you treated? *

Who is your PH doctor or specialist? *

What is the phone number of your PH doctor or specialist? *

What specialty pharmacy do you use? *

Scholarship Eligibility Requirements

We require that you have a PayPal account, as this is how we disperse funds. Do you have access to a PayPal account? *

Yes

What is your PayPal account name or associated email address? *

Do you agree to share your PH story with Team PH? *

Yes

Do you agree to let Team PH share your name and story on our website and social media channels to help us spread awareness about PH? *

Yes

Do you agree to share your purchase receipts with Team PH? *

Yes

In order to help more patients attend conference, applicants cannot receive financial assistance from other entities to attend the 2022 PH Conference. Do you agree to not accept or apply for financial assistance from entities other than Team PH? *

Yes

Do you agree to check in at the Team PH exhibit booth at the 2022 PH Conference? *

Yes

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