Through a generous anonymous donation from an Illinois Chapter member, the
Chapter is offering a scholarship to the
2004 HDSA National Convention, June 11, 12, and 13, in St. Louis, Missouri.
Perhaps for some of us, going to the
National Convention has been financially out of the question. As a member of
the Illinois Chapter, if you feel you
qualify for this scholarship, please submit your application on or before March
1, 2004 to the Chapter Office post office
address. The scholarship winner(s) will be notified by April 15, 2004. The scholarship
will include registration for the
convention, overnight accommodations at the convention hotel for Friday and
Saturday night, a per diem award for
food, and travel expenses to be determined by the scholarship committee for
the scholarship award winner.
WEIGHTING CRITERIA
The winner will be determined by the Chapter Scholarship Committee using a weighting
factor, which assigns points
valued between 0 and 3 (with 3 being the highest) based on the applicants response
to the questions on the
application.
WHY GO TO THE CONVENTION
The experience of attending an HDSA National Convention is invaluable to any
family living with Huntington's Disease.
It is at a national convention where they can hear, firsthand, the latest in
research directly from all of the wonderful
scientists and researchers who attend the convention.
The sessions are designed to help everyone from the caregiver, to those at-risk,
to the person with Huntington's
Disease and to our young adults and children living with HD, who have it or
are at-risk for it.
Lastly, the comradeship and lasting friendships that everyone will make at
a national convention is so heart-warming it
just cannot be experienced to the same degree on-line. It is truly a very rewarding
experience for anyone who is able
to attend. With the National Convention being held so close to us in St. Louis,
this offers a valuable experience for
anyone involved in the battle to find a cure of treatment for Huntington's Disease.
For further information, contact
Dave Hodgson, Illinois Chapter Convention Scholarship Chair at 630-569-0189.
Application can be found below. If you would like to apply for this scholarship,
please fill out the application and mail to:
HDSA, Illinois Chapter - P.O. Box 8383, Rolling Meadows, IL 60008
This application should be completed by the person who wants to attend the
convention. All information on the
application will be kept in the strictest confidence by the scholarship committee
members except for announcing the
name of the winning person[s].
Name ______________________________________________________________________________
Street Address ______________________________________________________________________
City/State/Zip_______________________________________________________________________
Phone __________________________________ (day) _____________________________
(evening)
Email: _____________________________________________________________________________
1. Please indicate whether you are:
a.) A person with Huntington's Disease: _____*
b.) A full time caregiver for a person with HD _____
c.) At-Risk for HD _____
* If you are a person with HD, please have an immediate member of your family
[or your primary care
physician] acknowledge below that you are able to travel without assistance.
2. Previous attendance at an HDSA National Convention
a.) Is this your first HDSA convention Yes [ ] No [ ]
b.) If not, how many have you attended _____
c.) Will you be attending alone Yes [ ] No [ ]
3. Immediate family members who are HD positive: ____________________________________
____________________________________________________________________________________
4. Financial Need
a.) How many people are employed in your household _____
b.) How many dependents are included in your household _____
c.) Is the sole income SSDI or similar funds _____
If you are unable to provide proof of income it is requested that a member
of your HD Support Group,
HDSA Chapter, an HD social worker or a clergy person sign [below] attesting
to the fact that financial
assistance is needed in order for you to attend the convention. This information
is required to support the
non-profit requirements of these funds.
If you would prefer not obtaining this signature, please attach a copy of your
most current tax filing or
any proof of financial need.
PERSON WITH HD:
If, as the applicant, you have Huntington's Disease, the name and signature
of an immediate family
member is required, attesting to the fact that you are able to travel to and
from the convention without
assistance .
I, (print name) ________________________________ the above applicant's (indicate
relationship)
________________________________hereby attest to the fact that the above applicant
is capable of
attending the 2004 HDSA National Convention on their own and will not require
any assistance from the
Hunt-Dis, the HDSF Committee, the HDSA or any other person(s) or facility:
Signature _________________________________________ Date _____________________________
Street Address ______________________________________________________________________
City/State/Zip_______________________________________________________________________
Phone __________________________________ (day) _____________________________
(evening)
Email: _____________________________________________________________________________
MINORS:
If, as the applicant, you are under the age of 18, the name and signature of
a parent or guardian is
required.
I, (print name) ________________________________ the above applicant's (indicate
relationship)
________________________________hereby attest to the fact that the above applicant
is capable of
attending the 2004 HDSA National Convention on their own and will not require
any assistance from the
Illinois Chapter of HDSA, the Scholarship Committee, the HDSA or any other person(s)
or facility
Signature _________________________________________ Date _____________________________
Street Address ______________________________________________________________________
City/State/Zip_______________________________________________________________________
Phone __________________________________ (day) _____________________________
(evening)
Email: _____________________________________________________________________________
FINANCIAL
I, _______________________(print or type name) hereby attest to the fact that
the above applicant requires
financial support in order to attend the 2004 HDSA National Convention.
Signature _________________________________________ Date _____________________________
Representing (Chapter, Clergy etc.)_____________________________________________________
Street Address ______________________________________________________________________
City/State/Zip_______________________________________________________________________
Phone __________________________________ (day) _____________________________
(evening)
Email: _____________________________________________________________________________
LIABILITY
Neither the members of the Illinois Chapter Board of Directors, the Committee
members for the Illinois
Chapter Convention Scholarship Fund, the HDSA nor the convention Hotel or its
staff assume any
liability for the safety and care of any person[s] awarded a Hunt-Dis Convention
Scholarship.
Acknowledgment of Responsibility:
I hereby accept full responsibility for my own safety and care should I be
awarded an Illinois Chapter
National Convention Scholarship.
Signature of Applicant: _________________________________________ Date:_________________
Created and maintained by Renette Davis. Send comments to Renette by clicking here.
Created: Feb. 8, 2004
Last updated: Nov. 15, 2010