The Canadian Society for Relapsing Polychondritis Bursary Application

CSRP Travel Bursary

This application and travel bursary is meant to support individuals and families of those who have been diagnosed or suspect a diagnosis of Relapsing Polychondritis. Funds allocated are to be used towards expenses incurred while travelling to a medical facility to confirm diagnosis, receive treatment, or participate in medical research.

Applications are reviewed monthly by the board of directors, and will be awarded with a maximum amount of $500.00 per person, per year, until the allocated funds for the bursary have been exhausted.

Please note: Once application has been received you will be contacted and asked to provide documentation verifying travel. Applicants must be a permanent resident of Canada.

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* 1. Please enter your contact information below. Applicants can be an individual with Relapsing Polychondritis (verified or unverified diagnosis), or a parent/legal guardian of a child with Relapsing Polychondritis (verified or unverified diagnosis).

Name:

Address:

Address 2:

City/Town:

Province:

Postal Code:

Country:

Email Address:

Phone Number:

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* 2. If this is for an applicant that is under the age of majority for your province, and you are their parent or legal guardian, please provide the following information (if not applicable, please click on question 3):

Child's full name:

Birthdate (YYYY/MM/DD):

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* 3. Has the applicant been diagnosed with Relapsing Polychondritis?

Yes

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* 4. If yes, please specify the type of Doctor who diagnosed,
(example: ENT, Rheumatologist, General Practitioner) and the year of diagnosis.

If no, (unverified diagnosis) please briefly explain the reasons why Relapsing Polychondritis is suspected.

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* 5. What is the purpose of the applicant's travel? (Please check all that apply)

Confirmation of diagnosis

Participation in research studies for Relapsing Polychondritis

Treatment advice or administration

Other (please specify)

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* 6. Where is the applicant travelling to?

Facility name:

Address:

City:

Province/State:

Country:

Contact (optional):

Date of travel (YY/MM/DD):

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* 7. Below, indicate the estimated travel cost for the applicant.
Please note, the maximum bursary awarded is $500.00, and that all invoices and/or receipts are to be submitted within 15 days (before or after) travel.

Airfare / Mileage (CAD):

Accommodations (CAD):

Meals (CAD):

Other travel related expenses (CAD):

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* 8. Media Release Authorization
If your application is accepted, the Canadian Society for Relapsing Polychondritis would like to acknowledge the bursary awarded. Please indicate to the CSRP if you do, or do not authorize the use of your name and information in publications by clicking "YES" or "NO" below:

"YES", I authorize the Canadian Society for Relapsing Polychondritis (CSRP) to use my first name, last name, initials, age, and city, to be published on the CSRP website and/or social media networks.

"NO" I do not authorize the CSRP to use my first name, last name, initials, age, or city in any publications on the CSRP website and/or social media networks.

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* 9. By clicking "YES", I am confirming that the applicant is currently a permanent resident of Canada.

"YES", the applicant is a permanent resident of Canada.

"NO", the applicant is not a permanent resident of Canada.

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* 10. By clicking "YES", you are accepting all the specifications of this application. You are also acknowledging to the CSRP that you understand the questions, and that the information provided on this application is accurate, truthful, and legal.

"YES", I fully understand and accept the specifications of this application, and acknowledge that ALL information provided on this application is accurate, truthful, and legal.

"NO" I do not accept the specifications of this application.

Question Title

* 1. Please enter your contact information below. Applicants can be an individual with Relapsing Polychondritis (verified or unverified diagnosis), or a parent/legal guardian of a child with Relapsing Polychondritis (verified or unverified diagnosis).

Question Title

* 2. If this is for an applicant that is under the age of majority for your province, and you are their parent or legal guardian, please provide the following information (if not applicable, please click on question 3):

Question Title

* 3. Has the applicant been diagnosed with Relapsing Polychondritis?

Question Title

* 4. If yes, please specify the type of Doctor who diagnosed,(example: ENT, Rheumatologist, General Practitioner) and the year of diagnosis. If no, (unverified diagnosis) please briefly explain the reasons why Relapsing Polychondritis is suspected.

Question Title

* 5. What is the purpose of the applicant's travel? (Please check all that apply)

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* 6. Where is the applicant travelling to?

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* 7. Below, indicate the estimated travel cost for the applicant. Please note, the maximum bursary awarded is $500.00, and that all invoices and/or receipts are to be submitted within 15 days (before or after) travel.

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* 9. By clicking "YES", I am confirming that the applicant is currently a permanent resident of Canada.

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* 10. By clicking "YES", you are accepting all the specifications of this application. You are also acknowledging to the CSRP that you understand the questions, and that the information provided on this application is accurate, truthful, and legal.

* 4. If yes, please specify the type of Doctor who diagnosed,
(example: ENT, Rheumatologist, General Practitioner) and the year of diagnosis.

If no, (unverified diagnosis) please briefly explain the reasons why Relapsing Polychondritis is suspected.

* 7. Below, indicate the estimated travel cost for the applicant.
Please note, the maximum bursary awarded is $500.00, and that all invoices and/or receipts are to be submitted within 15 days (before or after) travel.