Conference Scholarships

Please download, print this form and send it into the 5p- Society office

Application for Financial Assistance (2014)

Applicant’s Name: _______________________________________________________

Spouse’s Name (if applicable) ______________________________________________

Address: _______________________________________________________________

City: _______________________________ State/Providence: ____________________

Zip/Postal Code: ____________________ Home Phone: ________________________

Name of Child with Syndrome: _________________________________ Age: ________

How many other children are in the family: _________________

How many people will be attending the conference: __________

Has your family ever attended a conference _____________: If so, when? __________________

Applicant’s occupation/place of employment: ________________________________________________

Spouse’s occupation/place of employment: _________________________________________________

Please list any other agencies you have contacted for assistance and the results (provide supporting documents such as denial letters, etc) _____________________________________________________

On a separate sheet of paper (or the back of this application), please tell us a little about your situation, and what you hope to gain from the conference this year.

I have read and understood the guidelines surrounding this application.

___________________________                         _______________________

Applicant’s Signature                                                     Spouse’s signature (if applicable)

Mission:  To assist families financially so that they may attend a 5p- Society Conference.

GUIDELINES THAT FAMILIES MUST MEET

1.            The family must be a member of the 5p- Society, in good standing and be current with its membership dues.

2.            The family will understand that no cash or check will be furnished to them for the conference.

3.            The family must be able to travel to the conference on their own.  No travel arrangements will be financed.

4.            Decisions regarding the recipients of the conference scholarships will be handled through the Board of Directors or a committee appointed by the Board of Directors.  The Board of Directors has approved for five (5) conference scholarships to be awarded.

5.            The only items that will be financially aided are the Registration fee ($150.00) and the cost for one hotel room for three nights (Thursday, Friday and Saturday) (not including phone or other incidentals).  These items will be paid directly by the 5p- Society.  Again, no cash or check will be issued to a family.

6.            The family needs to show good faith effort in getting funding through another means.  For example, a state or local organization that provides funding must be contacted before asking for help from the 5p- Society.  This organization must be listed on the application.

7.            A family can only receive financial assistance once every three years.

8.            Submit a completed application by May 1, 2014 to:

5p- Society

Conference Scholarships

PO Box 268

Lakewood, CA  90714-0268

(888) 970-0777 or (562) 920-5240 – fax

director@fivepminus.org

9.            Letter of determination will be sent out to the scholarship recipients after May 15, 2014.