The Timothy Syndromes Alliance Scholarship Application for the 2019 SADS Annual Conference
The TSA (Timothy Syndromes Alliance) Scholarship Program was established to assist with travel expenses for TS families to attend the annual TSA gathering during the SADS Foundation Conference. Scholarship funds are available to assist families and individuals with registration, housing, and/or travel fees to attend this year's SADS Conference in Atlanta, Thursday, October 3 - Sunday, October 6, 2019.

TSA will be providing special sessions pertaining to information on LongQT 8 and Timothy Syndrome during the SADS conference. Attendees will be able to meet Katherine Timothy for whom the condition is named due to her hard work in following cases of children with LongQT 8 that appeared to be atypical than the other types of LongQT syndrome.

Members of TSA have worked hard to raise the money for this scholarship fund and we greatly appreciate their effort. It is intended to aid families and individuals who would otherwise be unable to participate in the Conference. If you can afford to come, it would be great to leave the scholarship funds for another family. If you’d like to help by raising money for your family’s expenses for the conference—or for research on Timothy Syndromes—we will be happy to help in any way we can.

The scholarships are provided with the following requirements:

1) A limit of one scholarship per family.

2) Please register for the SADS conference and use code: TIMOTHY19 which will waive your registration fees
https://events.r20.constantcontact.com/register/eventReg?oeidk=a07efy1k79vfef164c8&oseq=&c=&ch=

3) Assistance with one or all of the following: registration fees, hotel costs for up to 3 nights (one room up to 4 guests), and assistance with airfare/train.

4) A copy of the medical records* for all members of your family with a diagnosis of TS/LQTS 8. (We will provide more information on how to send these records as soon as you return this application to tsa@sads.org which is due Aug 31).

*The requirement for medical records will help TSA to build a database of all types of LongQT 8 with various mutations. This will be the first official recorded database of LongQT 8 and Timothy Syndrome. TSA wants to continue its efforts to raise money for more research and awareness of these conditions and this database will provide important information for these efforts. If you feel you are unable to acquire these records, please make a notation on the application.

All applications will be treated with strictest confidence. The application deadline is August 5th for the 2019 conference. There are a limited number of scholarships available, so please turn in your application as soon as possible.

Please keep in mind that if you receive a scholarship, you must make every effort to attend the conference sessions.

Return this form to tsa@sads.org by Monday August 5th.

Email address *
Parent Name(s) *
Your answer
Child Name(s) *
Your answer
Address (home address, city, state, zip) *
Your answer
Phone Number *
Your answer
What is the Calcium Channel Mutation that cause(s) LongQT 8 in your family? (Please provide the exact mutation as was reported to you via genetic testing) example - CACNA1C gene region exon 9 protein change Gly 406 (we will need a copy of the report emailed to tsa@sads.org) *
Your answer
How many people in your family have this mutation? (List names and birthdates of each) *
Your answer
Is affected person still alive? (If no, please provide date and explanation of death) *
Your answer
Name of the Electrophysiologist who treats the affected person and the name of hospital and its location with which the Electrophysiologist is related *
Your answer
For whom are you requesting scholarship funds (Name and relation to affected person) *
Your answer
For how much financial assistance are you applying? Please break down the costs. (Please know that the amount awarded will depend upon the number of other persons who apply and the scholarship amount available) *
Your answer
Who else will accompany the person receiving the scholarship funds? Please include names and ages. *
Your answer
Is this your first time attending a SADS conference? *
Thank you!
We very much hope you will be able to attend this conference and we are eager to see you. If you can’t come this year, start planning for attendance at a future conference. It is so helpful to be connected to others who face the same situation as well as the professionals who are working with and on behalf of us.

Thank you,

TSA (The Timothy Syndromes Alliance)
tsa@sads.org
www.sads.org/tsa

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