2018 Scholarship Application

Performing the World 2018
Financial Assistance Application
Please fill out a separate form for each person requesting support.
Check one:*

I request a scholarship for the full registration feeI will accept a partial scholarship for the registration fee if a full scholarship is not available.
Have you submitted a proposal to present at PTW 2018?*

YesNo
First/Given Name*
Last/Family Name*
Street Address*
City:*
State/Province/Region:*
Zip/Postal Code:
Country:*
Telephone Numbers (include country and city codes)
Work:
Home:
Mobile:
Fax
Email:*
Title and Affiliation
College or University (if you are a student)
Is a Visa required for you to enter the USA??*

YesNo
If you answered "yes," please complete the passport information below:
First Name EXACTLY AS IT APPEARS ON YOUR PASSPORT:
Last Name EXACTLY AS IT APPEARS ON YOUR PASSPORT:
Passport #
Date of Birth:

MonthDayYear
My gender is:
Have you attended an earlier PTW conference?*

YesNo
If yes, have you received financial assistance from PTW?

YesNo
In a few sentences, please let us know something about you, your desire to participate in PTW 2016, and your need for financial assistance. Please be specific.*
For more information please contact Melissa Meyer at ptw@eastsideinstitute.org or phone 212-941-8906.
Deadline: April 19, 2018
Should be Empty:

Performing the World 2018