If you know you can benefit from attending the conference and would like to apply for a scholarship for yourself, or if you’re already attending but would like to apply for a scholarship on behalf of a loved one so he or she can attend with you, please apply by answering the questions below.

The scholarship covers your conference registration and may cover some of your hotel room and tax. You are still responsible for transportation to and from the event, and for meals not provided by the conference.

You will be expected to provide the hotel with your credit card information for incidentals, and for one night of hotel and tax if you don’t show up or if you cancel within the hotel’s cancellation policy.

Apply right away, as we will begin allocating funds to applicants as soon as we begin receiving applications, and will do so until the funds are expended. In our efforts to help as many people as possible to attend the conference with the funds available, we cannot cover all conference-related costs for scholarship recipients.

This is for US attendees; international attendees can use our Contact Us link (https://www.stopafib.org/contact-us/) to send us the same information.

*1.Name(Required.)

First

Last

*2.Address(Required.)

Address *

Address 2

City/Town *

State/Province *

AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming

ZIP/Postal Code *

*3.Email(Required.)

*4.Phone(Required.)

*5.Are you a:(Required.)

Patient

Family member/Caregiver

*6.Have you previously attended the patient conference?(Required.)

Yes

No

*7.Submit an essay (from 200-1,000 words) explaining thoroughly why you or your loved one needs to be at the conference, and why it's a financial struggle for you.(Required.)

*8.I am aware that if my application is accepted and a scholarship awarded, I will still be responsible for transportation to and from the event, and meals not provided already by the conference, as well as some or all of my hotel costs. Even if the scholarship covers my hotel room and tax, I acknowledge that I will still be expected to provide the hotel my credit card information for incidentals, and for one night of hotel and tax if I do not show up or cancel within the hotel’s cancellation policy.(Required.)

Yes

No