HDSF Application

Deadline: Midnight 03/15/04

DUE DATE

As a member of the HUNT-DIS, the HD Caregivers, the Juvenile HD Caregivers, the HD National Youth Association or any other on-line Huntington's Disease Support group, you feel you qualify for this scholarship, please submit your application on or before midnight March 15, 2004.

WEIGHTING CRITERIA

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.

Either a partial or a full scholarship will be awarded depending the amount of funds collected. In 2004 the HDSF was able to award a full scholarship and several partial scholarships to help defray the costs of attending the convention to those winners. The same criteria applies to a partial scholarship.

APPLICATION

The form, below, can be copied and pasted on to a Word document to be mailed or you may download the application 2004 Application

As someone interested in applying for the 2004 HDSF please fill out this application and:

Snail-mail or email it to:

Jean Miller
1835 Pine Cone Circle
Clearwater, FL 33760-5349

NOTIFICATION OF WINNER

The scholarship winner(s) will notified by phone on 1 April 2004 with the announcement provided to the members of the HD on-line groups immediately afterwards.

2004 HuntDis~Lou Wilkinson

Convention Scholarship Fund Application

This application is to be completed by the person who wants to attend the HDSA 2004 National Convention in St. Louis. All information on your application will be kept in the strictest confidence by the HDSF-LW Committee Members except for announcing the name of the scholarship winner[s].

Name _______________________________________
Street Address ________________________________
City/State/Zip_________________________________
Phone ______________ (day) ____________ (evening)
Email: _______________________________________

1. Please indicate whether you are:
    a.) A person with Huntington's Disease: ____*
    b.) A full time caregiver for a person with HD ____
    c.) 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 that you are able to travel without assistance [below].

2. 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 _____

3. On-Line Huntingtons Disease Support Group Membership

Name of HD On-Line Support Group:______________________________________
URL {website] Of Support Group:______________________________________________

    a.) How long you have been a member of this group? _____
    b.) Do you participate in the group when time allows? _____

4. Immediate family members who are HD positive: ___

5. 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 ____

PROOF OF FINANCIAL HARDSHIP

If you are unable to provide proof of income with your application, you are requested to have a member of your HD Support Group, HDSA Chapter, a HD social worker or a clergy person sign the space provided below. This person is attesting to the fact that financial assistance is needed in order for you to attend the convention and is required to support the non-profit requirements of the HDSF-LW funds.

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

PROVIDE AN EXPLANATION OF "FINANCIAL NEED"

To help the Committee have a better understand your financial need, please use the following space to provide a short explanation. For example; your household is a one-income family and there are not any extra monies which can be used towards your attending this convention:

___________________________________________________________
___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

WHAT ATTENDING A CONVENTION MEANS TO YOU

In the space below, write a short paragraph of what being the recipient of a full or scholarship to the HDSA National Convention means to you:

___________________________________________________________
___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________
___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________

PERSON WITH HD:
If, as the applicant, you are Huntingtons Disease Positive you will need to provide the name and signature of an immediate family member attesting to the fact that you are able to travel to and from the convention without assistance . See space below.

I, (print name) ________________________________ am the above applicant's (indicate your relationship:) ________________________________ I hereby attest to the fact that the above applicant is capable of attending the 2004 HDSA Convention on their own and will not require any type of assistance from the HDSF-LW Scholarship, its Committee Members, the HDSA or any other person(s) or facility:

Signature ____________________________ Date __________________
Street Address ________________________________
City/State/Zip_________________________________
Phone ______________ (day) ____________ (evening)
Email: _______________________________________

MINORS - PARENT OR GUARDIAN APPROVAL

If, as the applicant, you are under the age of 18, you are required to provide the name and signature of a parent or legal guardian in the below space if they are not traveling to the convention with you.

I, (print name:) ________________________________ am the above applicant's (indicate your relationship:) ________________________________. I hereby attest to the fact that the above minor is able to attend the 2004 HDSA National Convention on their own and will not require any assistance or supervision from the HDSF-LW Scholarship, its Committee Members, the HDSA or any other person(s) or facility.

Check one: I will ____, I will not____ be attending the convention with the above applicant.

Signature ____________________________ Date __________________
Street Address ________________________________
City/State/Zip_________________________________
Phone ______________ (day) ____________ (evening)
Email: _______________________________________

FINANCIAL WITNESS

I, _______________________(print or type name) hereby attest to the fact that the above applicant requires financial support in order to attend the 2004 HDSA National Convention.

Signature _________________________________ Date ____________
Representing (Chapter, Clergy etc.)____________________________
Street Address ________________________________
City/State/Zip_________________________________
Phone ______________ (day) ____________ (evening)
Email: _______________________________________

Acknowledgment of Responsibility:

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

Signature of Applicant: _______________________ Date:_________

RELEASE OF LIABILITY - Neither the HDSF-LW Convention Scholarship Fund, its Committee members, the HDSA, the convention Hotel or its staff assume any liability for the safety and care of any person[s] awarded a HDSF Lou Wilkinson Convention Scholarship.