SPARK Grant Application Form

SPARK Grant Application Form
Applicant Information

Financial Aid for SPARK is open to non US Residents on a case by case basis. All Applicants must be registered members of The IgA Nephropathy Foundation and have a Verification of Diagnosis Form on file. (1) One Grant Application per family to help cover travel costs up to $1000. Grant is not to be used for additional hotel nights outside of the 2 nights included in registration. Priority consideration given to FIRST time SPARK Attendees. Children (0-12 years) are FREE but must be registered.
Name*

First NameLast Name
Relationship with IgA Nephropathy*

PatientFamily/Friend of Patient
Have you attended SPARK before*

YesNo
I would like to apply for SPARK Financial aid to help with:*

Registration Costs ($150/per person)Travel Costs (Airfare/Train/Etc)
Share your story with IgAN and what it would mean to attend SPARK*
Phone Number*

Country CodeArea CodePhone Number
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Date*

MonthDayYear
Date
Please upload a completed diagnosis verification form.*

Cancelof
REQUIRED Diagnosis Verification Form
Should be Empty:

Applicant Information