LGSOC Patient Conference Scholarship Request
All information shared within this form will be kept confidential. Completing this form does not guarantee that STAAR Ovarian Cancer Foundation will provide funds to help you attend the conference. We will reach out to you by January 10, 2025 with information on whether or not we can help you with your trip. We are working on obtaining sponsors to cover travel expenses for LGSOC patients who request help. LGSOC patients requesting scholarship funds must register for the conference before requests are considered. Please review the scholarship policy and guidelines found on the conference website.
Name
*
First Name
Last Name
Are you a LGSOC patient?
*
Yes
No
Date of Diagnosis
*
When do you plan on arriving to Houston?
*
February 6, 2025
February 7, 2025
February 8, 2025
When do you plan on departing Houston?
*
February 7, 2025
February 8, 2025
February 9, 2025
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Back
Submit
Next
With what do you need help in order to attend the conference? (choose all that apply)
*
Airfare
Accommodations
If you selected the airfare above, what is the current airfare price for you to travel to the conference?
Should be Empty: