NNPDF Family Support & Medical Conference Scholarship Application

APPLICATION INFORMATION

• * First Name:
• * Last Name:
• * Email Address:
• * Confirm Email Address:
• * Address 1:
• Address 2:
• * City:
• * State: --Choose-- Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -------------- Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Territory
• * ZIP Code:
• * Cell Phone:
• Phone:
• * Please list individual(s) with NPD:
• *

  NPD type associated with:

  • ASMD
  • NPC
• * Your relationship to individual with NPD:

• * Estimated total expenses for your family to attend the conference. Please include registration fees, travel, and hotel expenses.
• * Number of people attending (including adults and children):
• *

  Do you plan to stay/vacation in Orlando before or after the conference?

  • Yes
  • No
• If yes, please share the number of nights.
• *

  I would like to request hotel (room and tax only) assistance at the conference hotel for:

  • 1 hotel night $178.88 for July 20, 2023
  • 2 hotel nights $357.76 for July 20 & 21, 2023
  • 3 hotel nights $536.64 for July 20, 21 & 22 2023

• Hotel Room Cost: $159 per night (+tax & fees) = $178.88 (3 night maximum = $536.64)

• * Please explain how receiving the NNPDF Family Conference Scholarship will benefit your family:

• Is this your first time attending the NNPDF Family Support & Medical Conference?

  • Yes
  • No
• * Have you previously received funding from NNPDF to help attend conferences? If yes, please list year(s) you attended.
• * Name:
• * Date:

• Applicants will be notified of funding no later than April 15. Conference Registration must be received during the early bird registration period before May 1. Families registering after May 1, may pay the non- discounted registration fee.