National Hemophilia Foundation

 Application for Travel Grant
55^th Annual Meeting: “Many Stories, One Voice”
November 6 – 8, 2003

 Please answer all questions and submit applications by AUGUST 15, 2003.  Scholarship recipients will be determined through an equitable selection process conducted by NHF’s Consumer and Multicultural Task Forces and will be notified no later than OCTOBER 15^th.   Please do not contact NHF regarding the status of your application before this date. 

 Grant recipients must agree to participation in an interview to provide feedback to NHF regarding their experience at the Annual Meeting for possible use in HemAware or other NHF publications. 

Name of Person Submitting Application:

 Address:

Phone:

 Email:

 Name and relationship of attendees to applicant (Immediately family members only)

             1)

             2)

             3)

             4)

             5)

             6)

 Have you or any member of your family ever attended the NHF Annual Meeting?

 Describe which bleeding disorder you or your immediate family member has and provide the name and phone number of your physician or treatment center. 

Describe any socioeconomic barriers that, without access to a Travel Grant, would otherwise prevent you from attending the Annual Meeting. 

Please indicate your racial/ethnic background:

 ٱ Caucasian            ٱ African American  ٱ Latino   ٱ Asian/Pacific Islander             ٱ Other _________

Please indicate the areas which you will need assistance.

                       ____ Airfare

                      ____ Hotel 

            ____ Per Diem

           ____ Incidental Expenses

 Please send completed application form by AUGUST 15, 2003 to:

National Hemophilia Foundation
116 West 32^nd Street, 11^th Floor
New York, NY  10001
1-800-424-2634

ATTN:  Meetings – AM Travel Grants