2nd half

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, (type name) the above applicant's

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, (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"

QUESTIONS/COMMENTS

Please type any questions or comments you have for the HDSF Committee:

Date:

Name:

Address:

City:

State: Zip Code

Email Address:

I. RELATIONSHIP TO HD:

Please check the box indicating whether you are:

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, (type name) the above applicant's

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, (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"

QUESTIONS/COMMENTS

Please type any questions or comments you have to the HDSF Committe:

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