Yaya Foundation Family & Scientific Conference - Financial Assistance Request Form

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We are excited to host our second annual Family & Scientific Conference this year from October 13-14, 2023 at Children's Hospital of Philadelphia.

Please use this form to indicate that you may require financial assistance to attend the conference and/or to participate in a clinic and/or research visit with CHOP.

Please note that applications for financial assistance will be accepted until Saturday, July 15th at 11:59 p.m. ET. Notification of award of financial assistance will be provided by July 31, 2023.

Should you have any questions, please reach out to Yaya Foundation Executive Director Ben Smith at ben@yayafoundation4hl.org. Additional information regarding the conference is available on our website.

We are looking forward to seeing everyone at the conference!

Email *

Name *

Please provide your email address. *

Please provide the best phone number to reach you.

What kinds of services or programs do you offer? Please provide details (e.g., ages of participants, when the program is offered, duration of program, where the program/service is offered, etc.)

If you represent one specific geographic area, help us understand where families might look for similar programs/services).

Please indicate what type of financial assistance you may require (select all that apply). Please note that meals will be provided on Friday, October 13th and all day Saturday, October 14th. *

Yes

Hotel assistance

Air travel assistance

Car rental and/or gas assistance

Clinic Visit Assistance (if not covered by insurance)

Research Visit Assistance

Other

If you indicated "other above, please describe your need.

Are you traveling from an international location to attend the conference? *

Yes

Required

Please list any individuals (including children) who are planning to travel with you for the conference. *

Why do you want to attend the Yaya Family and Scientific Conference? What are you hoping to gain from the event?

Please use this space to tell us more about how financial assistance will be helpful to you. *

Please use this space to ask any questions you may have and/or provide any other comments. *

Thank you so much for your response! Financial assistance applications will be open until July 15th 2023, with award announcements being completed by July 31, 2023.

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