Pediatric PH Conference Scholarship Application
Families of pediatric PH patients are welcome to apply to receive $500 to attend PHA's 2020 International PH Conference. Funds may be used to cover registration costs for pediatric PH patients and their family members to attend the 2020 PH Conference. Before filling out this application, please be sure to carefully read the requirements to be a scholarship recipient below:

-Applicants must be a parent or legal guardian of a pediatric PH patient.
-Patient must be under 18 years old.
-Funds may only be used to cover conference registration costs for the patient and their family members.
-Applicants cannot receive financial assistance to attend conference from other entities in order to be a recipient of this fund.*
-International PH families are welcome to apply.
-Applicants must have a PayPal account for disbursement of funds.
-Applicants must provide registration confirmation as a receipt of purchase.
-Applicants must agree to share their PH story with Team PH.
-Applicants must agree to allow Team PH to share their name, photo, and PH story to use to in promotions.
-Applicants must agree to visit the Team PH booth at the conference.

*International applicants may receive financial assistance from other entities to attend conference.


Please be detailed when filling out the application. If you have any questions, please contact program manager Katie Werner at katie@teamphenomenalhope.org.
General Information
Patient's First and Last Name *
Your answer
Patient's Age *
Your answer
Parent/Legal Guardian's First and Last Name *
Your answer
FULL ADDRESS, City, State, Zip *
Your answer
Email Address *
Your answer
Phone Number *
Your answer
Tell us about why you and your family would like to attend conference. *
Your answer
How many members of your family are planning to attend the 2020 PH Conference? *
Your answer
Have you and/or your family members attended the PH Conference before? *
Patient Verification
What is the diagnosis of the patient? *
Your answer
Is the patient treated by a doctor for pulmonary hypertension? *
At what medical center is the patient treated? *
Your answer
Who is the patient's PH doctor or specialist? *
Your answer
What is the phone number of the PH doctor or specialist? *
Your answer
What specialty pharmacy do you use? *
Your answer
Scholarship Eligibility Requirements
We require that you have a PayPal account, as this is how we disperse funds. Do you have access to a PayPal account? *
What is your PayPal account name? *
Your answer
Do you agree to share your PH story with Team PH? *
Do you agree to let Team PH share your name and story on our website and social media channels to help us spread awareness about PH? *
Do you agree to share your registration confirmation for the 2020 PH Conference as purchase receipts with Team PH? *
In order to help more patients attend conference, applicants cannot receive financial assistance from other entities to attend the 2020 PH Conference. Do you agree to not accept or apply for financial assistance from entities other than Team PH? *
Do you agree to check in at the Team PH exhibit booth at the 2020 PH Conference? *
Submit
Never submit passwords through Google Forms.
This form was created inside of Team Phenomenal Hope. Report Abuse