Travel Assistance Scholarship Application for the 2016 Meeting for Adults with Fanconi Anemia

Deadline for Submission: December 15, 2015

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* 1. Name of Adult with FA:

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* 2. Age:

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* 3. Address Information:

Address:

City:

State/Province:

Postal Code:

Country:

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* 4. Telephone Number:

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* 5. Email Address:

Eligibility

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* 6. Have you previously received financial assistance through the scholarship fund? If yes, please list when (what year and for what meeting):

Scholarship funds are available to adults with FA (and in some cases, one guest) who would be unable to attend the meeting without such assistance. You are strongly encouraged to secure funding from other sources before applying for assistance through the Fanconi Anemia Research Fund.

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* 7. In addition, at least one of the following criteria must be met (please indicate eligibility):

I have been recently diagnosed with Fanconi anemia. Enter date of diagnosis below.

I have never attended an FA Family Meeting or Meeting for Adults with FA.

I have a major treatment decision within the year and need information available at this meeting. Please list anticipated treatment and date below.

I am from a country, which offers no FA education or support services (AND 1, 2 or 3 above has been checked); I am willing to start an FA support group in my country.

Enter Date of diagnosis and/or Anticipated treatment and date here:

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* 8. Additional information you’d like to share with the Scholarship Committee:

Travel Assistance Request

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* 9. Number of people in your party requesting assistance:

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* 10. Amount(s) Requested:

Airfare:

Gas (if driving):

Other:

Requests for assistance will be reviewed by the Fund’s Scholarship Committee, and recommendations can be expected within approximately one week of the review. Notification of status will be made by email unless otherwise requested.

Notes/Office use only:
Date received: Date sent for review:

Deadline for Submission: December 15, 2015