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Scholarship Application

2012 Patient and FamilyConference

October 26-28 San Diego, CA

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Applications must be submitted no later than Wednesday, October 3rd. Applications should be sent via email to or faxed to 877-643-3123. Scholarships will be awarded based on financial need and medical need, with priority considerationgiven to patients and to first-time attendees.

Applicants will be notified of the results via phone or e-mail no later than Wednesday, October 10th.

Scholarship funds are available to cover registration fees only. Applicants must confirm that they are able to cover their own travel and hotel expenses.

Your privacy is of the utmost importance. All information provided on this application is strictly confidential and will not be shared with anyone other than office staff and Board Members.

Name: ______

Address: ______

City: ______State: ______Zip: ______

E-Mail:______Phone:______

Have you ever attended our conferences before?

___Yes ___No Dates(s):______

Please explain why you would like to attend the Graves’ Disease & Thyroid Foundation’s 2012 Patient and Family Conference and what you hope to gain through the experience.

Conference scholarships are awarded to those with financial need. Please explain the circumstances that might make you eligible for scholarship funds.

Please describe any additional issues the Committee should consider and address in awarding a scholarship to you.

How would you use the knowledge gained at the conference to help yourself and other Graves’ disease patients and their families?

How are you currently involved in Foundation activities?

Scholarship funds are available to cover registration fees only; how will you be able to cover travel and hotel expenses?

I, ______, (print name) hereby certify thatI have need of funds to attend the 2012 Graves’ Disease & Thyroid Foundation’s Patient and Family Conference. I hereby certify that all statements in this application are true and correct. In addition, I have confirmed my ability to attend this conference with my physician (or minor child’s physician, if applicable.) I am aware that scholarship funds are only available to assist with registration fees; I will be able to cover my own travel and lodging expenses if I am selected to receive a scholarship.