ACHA Conference 2014 Karen McNulty Heart Heroes Scholarship Application

Applications must be received by ACHA by July 5, 2014, in order to be considered.

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.

The Scholarship Committee decisions are final.

Please note: Please apply for the MINIMUM scholarship support you need (if any). This will help ensure that as many individuals as possible can attend the conference. We encourage you to seek other funding from local sources, like a minister’s discretionary fund or a service organization’s outreach fund. Thanks in advance for your willingness to help us do all that we can for the ACHD community!

Contact Information

First Name *

Last Name *

Date of Birth *

Address 1 *

Address 2

City *

State *

Postal Code *

Phone *

Email Address *

Only ACHA members can receive a Karen McNulty Heart Heroes Scholarship. 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

Is an ACHD patient member or family member also applying? *

Yes

If yes, name of your ACHD patient or family member *

Each individual must complete a Karen McNulty Heart Heroes Scholarship application.

Did you receive a Karen McNulty Heart Heroes Scholarship in 2011 for the ACHA conference in Los Angeles? *

Yes

IF YES, PLEASE STOP HERE. You are not eligible for a 2014 Karen McNulty Heart Heroes Scholarship but you can apply for a Registration Scholarship. Click here to go to the Registration Scholarship page.

Please answer the following questions. All information is 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 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. I am requesting the following amount of financial asistance for myself. *

clear

1) Transporation - I am requesting the following amount for travel:

I am traveling by

I do not need financial assistance for transportation.

2) Hotel Preference: I will need a shared hotel room for: (Up to 3 nights)

a. Please indicate which nights

9/4/14

9/5/14

9/6/14

b. I have a preferred roomate

Yes

If yes, please indicate the name of the person you want to share a room with. *

I do not need financial assistance for a hotel room.

3) Registration: Please note that the ACHA Patient/Family Conference registration fee is significantly subsidized and covers less than half the per-person conference cost.

Minimum Required Registration is $95. How much are you willing to pay? *

If you receive a Karen McNulty Heart Heroes Scholarship, ACHA will help you with registering for the Conference, booking your hotel room, and/or arranging your travel. You will receive more information about these arrangements after your application has been reviewed. DO NOT make your own travel or hotel reservations.

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: *

We encourage you to return this application as soon as possible to maximize your chance of funding. The final deadline for Karen McNulty Heart Heroes Scholarship applications is July 5, 2014.

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