SCD Patient Scholarship

2020 Symposium Scholarships for Individuals with

Sickle Cell Disease

Please review this page and have all information ready once you are ready to submit, you cannot save and can submit only once. We will notify you of a decision within 14 business days. For budgeting & spacing purposes, we ask that you submit your application by September 18, 2020. Additionally, You may request a scholarship for (1) one caregiver.
Gender: MaleFemaleOther
Are you interested in clinical trials? YesNoMaybe
Your Organization or Affiliated Organization:
What are you seeking a scholarship for? FlightHotelRegistration
Preferred Departing Airport:
Preferred Airline:
Airline Rewards Number:
Seat Type Preferred:
AisleWindowMiddleNot the Emergency Row
Do you require a wheelchair? YesNo
Do you require a portable oxygen tank? YesNo
Please attach a letter verifying your medical clearance to fly (from Primary Care or other Specialty Doctor), if you require an oxygen tank :
Departure Day (Coming to Symposium)

It is preferred you arrive June 11, 2020, however, if you need to arrive June 10, please indicate why in your Statement of why you need assistance.
Preferred Departure time / time range:
You will be arriving at Fort Lauderdale International Airport OR Miami International Airport, whichever is the lesser of the ticket price. You are responsible for ground transportation to and from the hotel.
Departure Day (Leaving Symposium):
The meeting ends June 14, 2020 and therefore flights have a preferred to departure of the 14th. If you need to leave June 15, please give a detailed reason why in your Statement of Why You Need Assistance.
Preferred Departure time / time range:
Check-In Date:
Check-Out Date:
Do you prefer a Queen bed or Double Beds? QueenDouble BedNo Preference
Do you need a handicap accessible room? YesNo
If approved, you will receive a coupon code and will need to purchase your registration on our Symposium Registration page.
Statement on Why You Need Assistance and Why You Need to Attend:
Attached Statement from Primary Care or other Specialty Doctor confirming diagnosis of Sickle Cell Disease
Are you requesting a scholarship for a caregiver? YesNo
Caregiver Gender: MaleFemaleOther
Caregiver Are you interested in clinical trials?
Caregiver, Do you have Sickle Cell Trait? (required)
Caregiver's Organization or Affiliated Organization:
Why you need to attend with this individual with Sickle Cell Disease:
Please be advised that if your individual with Sickle Cell Disease is approved for a flight scholarship, you will be able to fly with them - you will be given a ticket based on the same flight departure time and departure airport. If they are approved for a hotel scholarship, you will be sharing the same room as them. If they are approved for a waived registration, you will also have a waived registration and will use a coupon code to register on our Symposium page website.

Would you like to become a member of the Sickle Cell Research Society of America? Memberships are $75.00/year per Individual with Sickle Cell Disease or Caregiver. If you select "Yes" you will be sent an email on how to sign up and what the benefits are.

YesNo

Any Additional Comments or Questions?