KCNQ2 Cure Summit Scholarship Application
Application for the 2020 KCNQ2 Cure Summit Scholarship program
Email address *
First Name *
Your answer
Last Name *
Your answer
Address *
Your answer
Have you previously applied for or received a scholarship to the KCNQ2 Cure Summit? *
Have you applied for funding from other resources for the Summit? *
If "Yes", from where?
Your answer
Scholarship Types
Four levels of scholarships are available:

Gold Level:
- Up to $200 per person for roundtrip airfare (up to four family members)
- Registration fees covered (up to four family members)

Purple Level:
- Registration fees covered (up to four family members)
- Two nights of hotel accommodations at the conference hotel

Blue Level:
- Two nights of hotel accommodation at the conference hotel

Green Level:
- Registration fees covered (for up to four family members)
* No other travel reimbursement/stipends will be provided

What's not covered in the scholarship:
- airport transfers
- parking
- checked bags
- meals not directly associated with the conference
- additional nights at the hotel above the those offered above
- hotel incidentals
Which scholarship are you applying for? *
Family *
Please list the first and last names of additional family members who will be attending the Summit with you . Include the ages of any children, as well as whether or not they have KCNQ2.
Your answer
Which days do you plan to attend the Summit (check all that apply) *
Please let us know your involvement in the KCNQ2 community and why attending the KCNQ2 Summit is important to you. This should be written in essay form and should be 500 words or less. *
Your answer
If you need more essay space....
Your answer
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