2023 Mitochondrial Medicine Symposium Family Scholarship Application

Scholarship Application - Patient Family and LHON Sessions

June 29-July 1, 2023 - Charlotte, NC

Submit this application form by April 15, 2023 (no payment required). Registration Information (once you receive an award notice by email or phone, UMDF will provide a registration code – no payment required with application):

Question Title

* Each person requesting a scholarship must complete and submit an application.

First Name: *

Last Name:

Address: *

City/Town: *

State: *

ZIP: *

Country:

Email Address: *

Daytime Telephone: *

Question Title

* In order to attend the 2023 symposium, I need scholarship assistance for the following:

Symposium Registration

Airfare

Car/Gas/Tolls (if driving)

Hotel

The Scholarship Award amounts for 2023 range from $100 to $500 per family and will be based on travel needs and availability. Scholarship award amounts will not exceed $500.

***Scholarship checks will be distributed upon completion of symposium – recipients must attend and complete a session voucher for at least three sessions per day to receive their scholarship funds.***

Requirements - you must be an affected adult and/or have an affected loved one to qualify for a scholarship.

To help us determine needs, please answer the following questions - preference for travel/hotel assistance will be given to those who provide details.

Question Title

* Have you approached other organizations for support to help defray the cost of attending symposium?

Yes

Other (please specify)

Question Title

* Have you attempted to raise any money yourself toward your expenses?

Yes

Other (please specify)

Question Title

* Have you previously been awarded any funds by the UMDF?

Yes

Question Title

* If yes, what year did you receive funding (note - scholarships were not awarded in 2020 and 2021 due to cancellation)?

2018

2019

2022

Question Title

* Please provide a brief explanation of your financial situation; include any information that you feel is relevant including any volunteer involvement you have with UMDF and any extraneous expenses you will incur by attending.