MDS Outreach Grant Application

MDS Outreach Grant Application
Type of Support Requested (select all that apply)*

MDS Endorsement (use of MDS logo in promotional materials)Funds to Support MDS FacultyFinancial Support for Event LogisticsFunds to support purchasing Zoom Webinar Account (MDS provides funding to support purchasing one month access to Zoom webinar. Amount awarded based upon anticipated attendance.)
A. CONTACT INFORMATION
Title of Meeting*
Organizing Body*
Institution, organization or other body
Meeting Location*
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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PROPOSED MDS FACULTY

Select # of Faculty*

1234

Faculty 1
Name of Faculty 1*

First NameLast Name
Institution*
City, Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Is faculty an MDS Member?*

YesNoUnsure
Lecture Title(s)*
Please indicate how this faculty member will be giving their lecture:*

OnlineIn-Person

Faculty 2
Name of Faculty 2*

First NameLast Name
Institution*
City, Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Is faculty an MDS Member?*

YesNoUnsure
Lecture Title(s)*
Please indicate how this faculty member will be giving their lecture:*

OnlineIn-Person

Faculty 3
Name of Faculty 3*

First NameLast Name
Institution*
City, Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Is faculty an MDS Member?*

YesNoUnsure
Lecture Title(s)*
Please indicate how this faculty member will be giving their lecture:*

OnlineIn-Person

Faculty 4
Name of Faculty 4*

First NameLast Name
Institution*
City, Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Email*
example@example.com
Is faculty an MDS Member?*

YesNoUnsure
Lecture Title(s)*
Please indicate how this faculty member will be giving their lecture:*

OnlineIn-Person

Budget Information
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)*
Maximum support offered is $10,000 USD
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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Agreement to Receive Funds

As the host organization, I agree to the statements below.
I am able to receive the applied for grant in full via wire transfer.*

I agreeI do not agree
I understand that MDS will not pay any portion of the grant to individual faculty listed in the application*

I agreeI do not agree
I understand that MDS will not book travel on behalf of the host or faculty member.*

I agreeI do not agree
I understand that if I am unable to accept the funds I will forfeit the grant award.*

I agreeI do not agree
Please note only applications that provide complete information will be considered.
Please allow 5-7 weeks for review.
Should be Empty:

MDS Outreach Grant Application

A. CONTACT INFORMATION

B. EVENT INFORMATION

PROPOSED MDS FACULTY