Power Up to the Summit - 2018
Scholarship Application
This application is to apply for Power Up to the Summit 2018 available to individuals with disabilities and/or family members of people with disabilities who benefit from assistive technology. All selected applicants must be able to attend all sessions on Monday, April 16, 2018 AND Tuesday April 17, 2018.
Date of Application:
Print Full Name:
I am a:
___ Person with a Disability
___ Parent of a Child Under 21 with a Disability
___ Parent of a Child Over 21 with a Disability
Address (Include Street Address, City, MO and Zip):
Primary Phone:
Primary E-mail:
Disability:
Describe the Assistive Technology You or Your Child Currently Uses or Would Like To Use:
Where do you usually obtain education for You or Your Child on assistive technology?
___ Therapist (OT, PT, SLP) ___ Special Educator ___ Friend ___ Internet Search ___ Vocational Rehab Counselor ___ Center for Independent Living ___ Other (Explain)______
Explainhow you see attending Power Up to The Summit 2018, helping you or your child.
If you are awarded the scholarship, what access needsto participate in the conference do you or your child have?
If you need an accessible room, circle one or the other:
___ Accessible walk in shower
___ Bath tub with grab bars
Scholarship Information
Scholarship is for the conference fee and two nights of hotel, April 15 & 16, 2018 (only for recipients residing greater than 50 miles from Columbia). Power Up is April 16 & 17, 2018at the Holiday Inn Executive Center in Columbia, Missouri. For more details, visit
I understand that as a recipient of the Power Up Scholarship funding, I will share the information I learn with other parents, persons with disabilities, or agencies/schools; and I will provide feedback to Missouri Assistive Technology on the impact of the AT knowledge gained.
I hereby give my permission to the Missouri Assistive Technology Advisory Council to use my name and likeness for purposes related to the organization’s publications,displays, websites, audio-visual presentations and other promotional, training, and educational materials.
I understand that by signing this document, I release the Missouri Assistive Technology Advisory Council from any and all claims and liabilities arising out of the usage of my name and likeness.
I understand that if granted a scholarship, if I am unavailable to attend closer to the conference or, the day of the conference I will contact Missouri Assistive Technology and Jamie, Custom Meeting Planners at (573) 445-2965, and decline the grant so others may participate.
Sign Name:Return completed application via mail, fax or e-mail by February 25th, 2018.
Missouri Assistive Technology
1501 NW Jefferson Street
Blue Springs, MO 64015
(816) 655-6700 (V) & (816) 655-6710 (Fax) (e-mail)