MDS Outreach Application

MDS Outreach Application
ONLY PROGRAMS THAT TAKE PLACE IN NO FEE COUNTRIES ARE ELIGIBLE FOR MDS OUTREACH PROGRAMS.

Current List of No Fee Countries

Please note only applications with complete information will be considered.
Please allow 5-7 weeks for review.
A. CONTACT INFORMATION
Title of Meeting*
Primary Organizer*
Meeting Location*
Is this Organization an MDS Affiliate Member Society?*

YesNoUnsure
Have you received Outreach Program funding for this program in previous years?*

YesNo
If yes, please list year and grant amount:*
Contact Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Phone Number*

Country CodeArea CodePhone Number
Fax Number

Country CodeArea CodePhone Number
B. EVENT INFORMATION
Meeting Website*
Meeting Start Date*

MonthDayYear
Start Date
Meeting End Date*

MonthDayYear
End Date
Person with Fiduciary Responsibility (Name, Title)*
Location where Financial Accounts are Held*
Planning Committee Members*
Briefly describe the meeting:*
What language(s) will the meeting be presented in?*
Anticipated Attendance (#)*
Recommended Audience (select up to 2)*

ClinicianFellow / Resident / StudentResearcherHealth ProfessionalOther
Clinician - please specify:*

Movement Disorder SpecialistGeneral NeurologistPrimary CareResearcherOther
Health Professional - please specify:*

Nurse / Nurse PractitionerPhysio / Physical TherapistOccupational TherapistSpeech TherapistPhysician AssistantGenetic CounselingPsychologistOther
Upload the Event Program / Schedule containing Names of Faculty*

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Please indicate how you will be promoting the meeting (select all that apply):*

EmailWebsiteBrochure / PostcardOther
Are you requesting funding for event logistics? (i.e. venue rental, food and beverage, etc.)*

YesNo
Virtual Support Type Requesting (Select all that apply):*

MDS Endorsement (Use MDS logo on promotional materials)Funds to support purchasing Zoom Webinar Account (MDS provides funding to support purchasing one month access to Zoom webinar. Amount awarded based upon anticipated attendance.)Funds to support MDS Faculty
Select # of Faculty*

12

Please specify the type of grant support you’re requesting from MDS (Select all that apply):*

MDS Endorsement (Use of MDS logo on promotional materials)Funds to support MDS FacultyFunds to support event logistics
Select # of Faculty*

1234

Total Projected Income (USD)*
Amount in USD
Total Projected Expenses (USD)*
Amount in USD
Projected Gain / Loss (USD)*
To calculate: Income - (minus) Expenses = Gain / Loss
Amount of MDS Support Requested (USD)*
Amount in USD
If you are requesting more than $10,000 USD, please provide a reason.
Attach a complete budget including details on the projected income and expenses. Please enter summary figures from above in the attached budget.*

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Please upload any additional information you deem important.*

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Please note only applications that provide complete information will be considered.
Please allow 5-7 weeks for review.
Should be Empty:

MDS Outreach Application

A. CONTACT INFORMATION

B. EVENT INFORMATION