This application should be made out by the person who wants
to attend the 2003 HDSA National HD Convention (i.e. the "applicant".) All of the information requested
on this application will be kept in the strictest confidence by the HDSF Committee Members except for announcing the winning
persons name.
MAILING INFORMATION
Applications containing attachments must be mailed to:
HDSF Committee
c/o 1835 Pine Cone Circle
Clearwater, FL 33760-5349
ELECTRONIC SIGNATURES:
The HDSF Committe will accept an emailed application from applicant
using theiremail address as an acceptable "signature".
For those Sections, below, requiring persons other then the applicant's
signature we will accept an email from their email address as an acceptable "signature". If they are unable
to send an email, then a hard copy of their signature will be required and should be mailed to the above address.
All electronic "signatures" should be sent to: Jean Miller
AUTO-RESPONDER~CONFIRMATION REQUIRED
Since this is an auto-responder, the information will be "automatically" emailed to a Hunt-Dis Convention Scholarship
committee member. In order for the application to be accepted by the committee, the applicant will
be required to send a confirmation email to Jean Miller indicating that you are the individual who submitted the auto-responder
application. This is required since the auto-responder does not reflect a "from" field.
APPLICATION~INFORMATION REQUIRED
Date:
I. RELATIONSHIP TO HD:
Please indicate with an "X"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 (in appropriate space provided
below) that you are able to travel without assistance.
II. CONVENTION ATTENDANCE INFORMATION
a) Is this your first HDSA convention: b) If
not, how many have you attended: c) Will you be attending alone:
III. ON-LINE MEMBERSHIP INFORMATION
I am a member of Hunt-Dis and/or the HD or JHD Caregiver
group(s)
a) How long you have been a member of this group?
b) How often do you participate
in the group when time allows?
IV. FAMILY MEMBERS WITH HD
How many family membersin, your immediate household, including the applicant:
V. FINANCIAL INFORMATION
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
d) The household total annual income in the
last calendar year was:
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.
FOR
APPLICANTS WITH HD:
If the applicant has HD, the name and signature of an immediate
adult family member or legal guardian is required, attesting to the fact that the applicant is able to travel to and
from this convention without assistance . This is required because neither the Hunt-Dis, the Hunt-Dis
Committee, the HDSA or its convention staff or the Hotel or any other person will be responsible for the person during
this time:
I, (print name) the
above applicant's (indicate relationship) hereby attest to the fact that the above applicant is capable of attending the
2003 HDSA National HD Convention on their own, should their application be approved, and will not require any
assistance from the Hunt-Dis, HDSA or any other person(s) or facility:
Signature
Date:
Name:
Address:
City:
State: Zip Code
Email Address:
Note: see above for the acceptance of "electronic
signatures"
MINORS:
If the applicant is under the age of 18, the name and signature of
a parent or guardian is required.
I, (print name) the above applicant's
(indicate relationship) hereby attest to the
fact that the above applicant is capable of attending the 2003 HDSA National HD Convention on their own and will not require
any assistance from the Hunt-Dis, HDSA or any other person(s) or facility.
I hereby provided my approval for this minor to attend the convention,
should their application be approved, to attend the 2003 HDSA National HD Convention without an adult-supervision required
by any of the above mentioned parties:
Signature:
Date:
Name:
Address:
City:
State: Zip Code
Email Address:
Note: see above for the acceptance of "electronic
signatures"
FINANCIAL HARDSHIP
I, (print or type name) hereby attest to the fact that the above applicant
requires financial support in order to attend the 2003 HDSA National HD Convention.
Signature: Representing (Chapter, Clergy etc.)
Address:
City:
State: Zip Code
Email Address:
Note: see above for the acceptance of "electronic
signatures"
APPLICANT: RELEASE OF LIABILITY
The members of Hunt-Dis, the HDSF committee , the HDSA
or its convention staff or the Hotel or any other person 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:
Note: see above for the acceptance of "electronic
signatures"
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.
Date:
I. RELATIONSHIP TO HD:
Please indicate with an "X"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. ATTENDANCE AT PREVIOUS HDSA CONVENTIONS
a) Is this your first HDSA convention: b) If not, how many have you
attended:
c) Will you be attending alone:
III. MEMBERSHIP
I am a member of Hunt-Dis/HD or JHD Caregiver
a) How long you have been a member of this group?
b) Do you participate in the group when time allows?
IV. FAMILY MEMBERS WITH HD
How many family membersare
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 2003 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:
Name:
Address:
City:
State: Zip Code
Email Address:
Note: If family member can email their acceptance directly to Jean Millerthat will be accepted as a "signature", otherwise a hard copy of the application will need to be mailed.
MINORS:
If the applicant is under the age of 18, the name and signature
of a parent or guardian is required.
I, (print name)the above applicant's (indicate relationship)hereby attest to the fact that the above applicant is capable of
attending the 2003 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:
Name:
Address:
City:
State: Zip Code
Email Address:
Note: If parent or guardian can email their approval directly to
Jean Miller that will be accepted as a "signature", otherwise a hard copy of the application will
need to be mailed.
FINANCIAL
I, (print or type name) hereby
attest to the fact that the above applicant requires financial support in order to attend the 2003 HDSA National Convention.
Signature: Representing (Chapter, Clergy etc.)
Address:
City:
State: Zip Code
Email Address:
Note: If person can email their approval directly to Jean Millerthat will be accepted as a "signature", otherwise a hard copy of the application will need
to be mailed.
LIABILITY
The members of Hunt-Dis, or the committee for the Hunt-Dis Convention Scholarship 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.
