ACHA Conference 2014 Registration Scholarship Application

Registration Scholarship applications must be received by ACHA by July 5, 2014, in order to be considered.

If you are also applying for assistance with travel or hotel, please fill out the Karen McNulty Heart Heroes Scholoarship Application and do NOT fill out this form.

You may submit your application:

Online by submitting this form
By postal mail (PDF) to ACHA, Scholarship Committee, 6757 Greene Street, Suite 335, Philadelphia, PA 19119
Fax to 215-849-1261
Email to pmiller @achaheart.org

(If you plan on submitting your application using numbers 2-4 above please feel free to print this form)

Your privacy is of the utmost importance to ACHA. All information provided on this application is strictly confidential and will not be shared with anyone beyond the Scholarship Committee and selected office staff.

All Scholarship Committee decisions are final.

Please note that the ACHA Patient/Family Conference registration fee is significantly subsidized and covers less than half the per-person conference cost. We offer registration scholarship support for those who would otherwise not be able to attend. Please apply for the MINIMUM scholarship support you need (if any). By doing so, you will help ensure that as many individuals as possible can participate in the upcoming event. Thanks in advance for your willingness to help us do all we can for our community!

Contact Information

First Name *

Last Name *

Date of Birth *

Address 1 *

Address 2

City *

State *

Postal Code *

Phone *

Email Address *

All Registration Scholarship recipients must be ACHA members. If you are not an ACHA member, you will automatically become one by completing this application and agree to receive email and postal mail communications from ACHA.

Please Select your demographic category: *

ACHD Patient

ACHD Family Member

Please answer the following questions. All information will be kept confidential.

Have you ever attended an ACHA National Conference before? *

Yes

If yes, when? *

Is it especially important that you attend this year? *

Yes

If yes, why? *

What's the one thing you want to take away from this conference? *

Please tell us a little about your diagnosis and health situation. *

Please describe your family and tell us a little about your financial situation by answering these questions:

Do you work outside of the house? *

Yes

Does any other adult in your house work? *

Yes

If yes, who works?

How many people live in your house? *

What are your sources of income? *

What is your total family income (approximately) per year? *

Please include any relevant information about your financial needs that would help us to understand your needs for a conference registration scholorship. *

I agree to promote ACHA and the ACHA 7th National Conference on my social media sites and to my family, friends and personal social networks. *

Yes

I agree to volunteer at the National Conference, if needed. *

Yes

I hereby certify that I have need of registration funds to attend the ACHA National Conference in Chicago September 5-7, 2014. *

clear

Conference Registration (includes Gala attendance)

Cost of registration: Early Bird $225/ Full cost $275 ** Minimum Required registration is $95. *

I read the information given for registration fees above.

How much are you willing to pay? *

By initialing and dating, below I agree that I have read and completed all the sections of the above application and the information provided is correct. I understand that I must pay a minimum of $95 for registration in order to be considered for a scholarship. I also understand that upon notification of my scholarship award, I will have 7 days to accept or decline the scholarship. If I accept a scholarship, I agree to: 1) Promote ACHA and the ACHA National conference via my social media sites and to my family, friends, and personal social networks and 2) Volunteer at the conference if needed.

Initials: *

Date: *

The final deadline for the Registration Scholarship applications is July 5, 2014.

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