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 100% of survey complete.
Thank you for your interest in attending this year's Congenital Heart Legislative Conference.  

There are a limited number of scholarships available.  Your application does not guarantee that you will receive a scholarship.

Applications will be reviewed by our team and you will be notified no less than four (4) weeks prior to the event. 

It is our policy to provide equal opportunities without regard to race, color, religion, gender, sexual preference, age or disability. 

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* 1. First Name

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* 2. Last Name

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* 3. Address

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* 4. City

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* 5. State

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* 6. Zip Code/Postal Code

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* 7. Phone Number

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* 8. Email Address

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* 9. Date of Birth (MM/DD/YYYY)

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* 10. Please indicate your relationship to CHD.

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* 11. What kind of CHD are you or your family member affected by? (list all that apply)

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* 12. Have you attended a Legislative Conference or Lobby Day in Washington, DC before?

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* 13. Have you ever received a scholarship to attend an event focused on CHD in the past?

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* 14. Briefly describe how you and/or your family members would benefit from attending this conference.

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* 15. Please list how you and/or your family have participated in CHD related activities.  This can include legislative events, leading or speaking at support groups/meetings, participating in fundraising/walk events, etc.

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* 16. As an advocate, please describe ways you and/or your family can assist with raising awareness about CHD.

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* 17. Number of people in your household.

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* 18. Please list your annual household income.

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* 19. How many people from your household will be attending the conference?

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* 20. Please rank, in order of importance, the financial assistance needed based on the information above. (This does not guarantee assistance level).  Transportation: (Air, Train, Bus or Car); Accommodations (Hotel); Application/Registration (Fee); Meals during travel time.

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* 21. Please itemize the total estimated allowable expenses (value based on your research) for all family members listed above to attend the conference.

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* 22. Please feel free to use this comment field to provide us with any additional information that should be included within your scholarship application.

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* 23. Type your first and last name, which will be considered as your signature for this form.

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