2013 Summit Travel Award

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* 1. Full name of travel award applicant

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* 2. 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.

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* 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)

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* 4. 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.