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HDSF Application
The Hunt-Dis Scholarship Fund

This is the 2003 HDSF Application

If you are a member of Hunt-Dis and feel you would qualify for this fund, please submit your application on or before March 1, 2002.

The winner will be determined by the HDSF Committee using a weighting factor, which assigns points valued between 0 and 3 (with 3 being the highest) based on the applicants response to the questions on the application.

This application in Word format may be obtained by contacting Jean Miller at jemiller@tampabay.rr.com

As someone interested in applying for the 2002 HDSF please fill out this application and mail it to:

Shana Martin
1725 Laurel Crest
Madison, WI 53705

The winner(s) will notified by phone on 15 March 2002 with the announcement provided to the members of Hunt-Dis immediately afterwards. Either a partial or a full scholarship will be awarded depending the amount of funds collected.

2002 HUNT DIS
CONVENTION SCHOLARSHIP APPLICATION

This application should be made out by the person who wants to attend the convention. All information on this application will be kept in the strictest confidence by the HDSF Committee Members except for announcing the winning persons name.

NAME _______________________________________
ADDRESS ____________________________________
CITY/STATE/ZIP ______________________________
PHONE ______________ (day) ___________ (evening)
EMAIL: ______________________________________

I. Please indicate whether you are:

A person with Huntington's Disease: ____*
A full time caregiver for a person with HD ____
At-Risk for HD ____

* If you are a person with HD, please have an immediate member of your family or your primary care physician acknowledge (below) that you are able to travel without assistance.

II. Previous attendance at an HDSA National Convention

a) Is this your first HDSA convention _____
b) If not, how many have you attended _____
c) Will you be attending alone _____

III. Hunt-Dis Membership

a) How long you have been a member of Hunt Dis _____
b) Do you participate in Hunt-Dis when time allows?_____

IV. Immediate family members who are HD positive: ___

V. Financial Need

a) How many people are employed in your household ____
b) How many dependents are included in your household ____
c) Is the sole income SSDI or similar funds ____

Since the HDSF does not want you to have to provide proof of income it is requested that a member of your HD Support Group, HDSA Chapter, an HD social worker or a clergy person sign (below) to attest to the fact that financial assistance is needed in order for you to attend the convention. This information is required to support the non-profit requirements of these funds.

If you would prefer not obtaining this signature, please
attach a copy of your most current tax filing or any proof of financial need.

PERSON WITH HD:

If the applicant has HD, the name and signature of an immediate family member is required, attesting to the fact that the applicant is able to travel to and from this convention without assistance .

I, (print name) ________________________________ the above applicant's (indicate relationship) ________________________________hereby attest to the fact that the above applicant is capable of attending the 2002 HDSA Convention on their own and will not require any assistance from the Hunt-Dis, HDSA or any other person(s) or facility:

Signature ____________________________ Date ___________
Address: _____________________________________________
Phone Number:______________
Email:_____________________

MINORS:

If the applicant is under the age of 18, the name and signature of a parent or guardian is required, attesting to the fact that the applicant is able to travel to and from this convention without assistance.

I, (print name) ________________________________ the above applicant's (indicate relationship) ________________________________hereby attest to the fact that the above applicant is capable of attending the 2002 HDSA Convention on their own and will not require any assistance from the Hunt-Dis, HDSA or any other person(s) or facility:

Signature ____________________________ Date ___________
Address: _____________________________________________
Phone Number:______________
Email:_____________________

FINANCIAL

I, _______________________(print or type name) hereby attest to the fact that the above applicant requires financial support in order to attend the
2002 HDSA National Convention.

Signature: _____________________________________________
Representing (Chapter, Clergy etc.)_________________________
Address: _______________________________________________
Phone Number:______________
Email:_____________________

LIABILITY

The members of Hunt-Dis, or the committee for the Hunt-Dis ConventionScholarship Fund, assumes no liability for the safety and care of any person awarded a scholarship.

I hereby accept full responsibility for my own safety and care should I be awarded a Hunt-Dis convention scholarship.

Signature of Applicant: _______________________ Date:_________