VHF Terry Lamb Enrichment Scholarship

VHF Terry Lamb Enrichment Scholarship
Go here to read the Terry Lamb Enrichment Scholarship Application Procedure & Guidelines.

If you have questions about this scholarship please reach out to Kelly Waters at 804-740-8643 or kelly@vahemophilia.org
Please confirm that you have read the Terry Lamb Enrichment Scholarship Application Procedure & Guidelines*

I confirm that I have read the Terry Lamb Enrichment Scholarship Application Procedure & Guidelines.
Name of applicant*

First NameLast Name
Date of birth*

MonthDayYear
Date
Is the applicant under 18 years of age?*

YesNo
Name of Parent or Guardian if applicant is under 18 years of age*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number *
If applicant is under 18, Please enter the parent/caregiver's phone number.
Email*
If applicant is under 18, Please enter the parent/caregiver's email address.
How did you hear about VHF's Terry Lamb Enrichment Scholarship?*

Internet SearchSocial MediaFriend/Family MemberHealthcare ProviderVHF email and/or at an eventOther
What are you applying for?*

Travel grant to a national meetingScholarship for a program or activity
What national meeting are you applying for?*

National Bleeding Disorders Foundation (NBDF) Bleeding Disorders ConferenceNational Bleeding Disorders Foundation (NBDF) Washington DaysOther
Please list the first and last name and the age (if under 18) of family/household members that will attend the meeting with you.*
Please describe the program and/or activity that you are applying for?*
Start date of program and/or activity*

MonthDayYear
Date
Cost of program and/or activity*
Payment deadline of program and/or activity*

MonthDayYear
Date
Have you or a family/household member ever received funding or a scholarship from VHF?*

YesNoI am unsure
If yes, what was the funding for and how much was it for?*
Do you have an inherited bleeding disorder?*

YesNo
What type of inherited bleeding disorder do you have?*

Hemophilia AHemophilia BVon Willebrand DiseasePlatelet DisorderRareFactor DeficiencyOther
Where do you receive treatment for your bleeding disorder?*
If you answered no, please list which family/household member(s) does and their relationship to you.*
Does the affected family member live in your household?*

YesNoOther
What type of inherited bleeding disorder does your family/household member have?*

Hemophilia AHemophilia BVon Willebrand DiseasePlatelet DisorderRareFactor DeficiencyOther
Where does the family/household member with an inherited bleeding disorder receive treatment for their bleeding disorder? *
Would you be willing and/or able to still participate in the meeting, program and/or activity if a partial scholarship is offered/available?*

YesNoMaybe
If you answered no or maybe, please explain*
How has an inherited bleeding disorder affected you and/or your family’s lives? Your response should be a minimum of 100 words.*
Explain what you hope to gain by participating in this meeting, program, and/or activity. Your response should be a minimum of 100 words. *
Describe your previous participation with the chapter and how you plan to contribute to VHF and support persons with inherited bleeding disorders. Your response should be a minimum of 100 words.*
Declaration of Application

I certify that the information I have submitted is true and accurate to the best of my knowledge. I authorize the release of information to VHF to verify all statements made in this application. Disclosing false information may jeopardize my award at any time. I also give permission to use my name/and or photo in VHF’s website, VHF News, or any other press release that VHF deems appropriate.
I have read, understand, and agree.*

Yes
Signature applicant*

Clear
Signature of parent/guardian if applicant is under the age of 18

Clear
Today's date*

MonthDayYear
Date
Should be Empty: