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2003 HUNT-DIS HDSA
CONVENTION SCHOLARSHIP APPLICATION AUTO-RESPONDER

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 Committee will accept an emailed application from applicant using their email 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:

Name:

Address:

City:

State: Zip Code

Email Address:

I. RELATIONSHIP TO HD:

Please check the box indicating 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 members in your immediate household, including yourself, have Huntington's Disease:

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) What was total annual income, in the last calendar year, for your household:

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, (type 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:

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:

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.
I am Representing (Chapter, Clergy etc.) You may contact me at:

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"

Other comments from Applicant: