NephCure Patient Summit Scholarship Application
Thanks to our sponsors, NephCure is able to provide a limited amount of scholarships to those patients that would otherwise not be able attend. Scholarship awards are based on need and funding. Please be detailed in your responses.
Name
*
First Name
Last Name
You/Your Loves One's Diagnosis
*
Patient Name (If different from self)
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient's Date of Birth
*
-
Month
-
Day
Year
Date
Patient's Race/Ethnicity
*
Please Select
Asian
Black or African American
Hispanic or Latino/Latinx
Native Hawaiian or Other Pacific Islander
White or Caucasian
African or Afro-Caribbean
Middle Eastern or North African
Native American
East Asian
South Asian
Southeast Asian
Multiracial
Other/Prefer not to say
Have you received a scholarship in the past? If so, for which events?
*
Knowing that there is a limited amount of scholarship funding, which scholarship package below would make it possible for you to attend the Patient Summit?
*
Please Select
Airfare
Hotel ($300 for two nights)
Airfare + Hotel
What are you hoping to gain from the Patient/Youth Summit and why would financial assistance benefit you?
*
Scholarships are available for 1 adult patient or 1 parent and 1 youth patient (ages 8-18). Please list the name(s) and age(s) of proposed attendees. You must input the ages of the attendees.
*
Submit
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