2018 Alliance DC Trip Registration & Scholarship Application
The Alliance for Appalachia is planning a trip to DC to advocate for the RECLAIM Act and Black Lung benefits in September. We can provide scholarships for up to 40 people which include lodging, food, and some travel. This form will help us prioritize scholarships among our participants.

The trip is from September 23rd - 26th and will include meeting with congressional representatives, networking, and fellowship. Please contact the Alliance for Appalachia or the person who sent you this form with any further questions. A schedule of events will be announced after registration closes Aug 23rd.

Contact Information
Please provide the following contact information.
Last Name *
Your answer
First Name *
Your answer
Gender Pronouns *
Your answer
Phone *
Your answer
Email *
Your answer
Organization *
Your answer
If you are not a member of the Alliance for Appalachia then which member organization referred you to apply?
Your answer
Travel & Accommodations
Please answer the following so we can reserve lodging, plan meals, and if possible connect your to carpool opportunities.
Please plan to carpool. It's fun and a great opportunity to prep for the trip with others! Do you need carpool or ride-share assistance and from what state? *
What nights do you need lodging? *
Required
What time will you arrive on your first night? Please estimate. *
Your answer
The Alliance for Appalachia will provide group meals and support for meals on your own. What days do you anticipate being on the trip so we can estimate meal costs accordingly? *
Required
Do you have any dietary restrictions?
Your answer
Will your organization be contributing towards any costs of the trip and if so how much? *
Your answer
On the Issues
Please share a little about why you feel supporting these issues and this trip is important to you.
What has been your involvement with the RECLAIM Act and/or how do you relate to living in communities impacted by coal mining? *
Your answer
What is your personal connection to black lung disease? *
Your answer
How do you feel RECLAIM and Black Lung issues are related to your work or experiences living in Appalachia?
Your answer
Thank you!
We will contact you very soon! Thank you for your participation.
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