2013 Summit Travel Award Survey

1. Full name of travel award applicant

Full name of travel award applicant

2. I have a form of arthritis. Please indicate all that apply below.

I have a form of arthritis. Please indicate all that apply below. Osteoarthritis (OA)

Rheumatoid Arthritis (RA)

Juvenile Arthritis (JA)

I have a family member with Arthritis (please specify below)

Other

If your answer was other please specify.

3. If the nominee is under the age of 18, please list the accompanying adult. (Please note that any youth attending the Summit must be in grades K-12th)

If the nominee is under the age of 18, please list the accompanying adult. (Please note that any youth attending the Summit must be in grades K-12th)

4. The Arthritis Foundation is committed to serving diverse communities. We encourage racial and ethnic minorities to apply for our travel awards. Race/Ethnicity:

The Arthritis Foundation is committed to serving diverse communities. We encourage racial and ethnic minorities to apply for our travel awards. Race/Ethnicity: White/Caucasian

Black/African American

Hispanic/Latino

Asian American

Native Hawaiian or other Pacific Islander

American Indian or Alaska Native

Other

Prefer not to answer

If your response was other please comment.