Congenital Hyperinsulinism International

Scholarship Application

Congenital Hyperinsulinism International is offering a limited number of scholarships for hyperinsulinism families in need of financial support attending the 2018 Congenital Hyperinsulinism International Family Conference at the Hilton Garden Inn Fort Worth Medical Center Hotel. The scholarship will cover the cost of one night at the Hilton Garden Inn Fort Worth Medical Center Hotel. We encourage anyone for whom this would be helpful to apply and we thank you for taking the time to complete this form. (All information provided in this application will be held in the strictest confidence). Please send an email to jschmitt@congenitalhi.org if you have questions.

CHI must receive this application by July 15, 2018. Notifications of awards will be made on a rolling basis. CHI has a budget to offer a scholarship for just one night (July 28) for those HI families with a need for the scholarship who are attending (even if only one member is attending). We recognize that you may want to make a reservation for July 27. If you wish to stay two nights and are applying for the scholarship, please make your reservation for July 27 here: http://hiltongardeninn3.hilton.com/en/hotels/texas/hilton-garden-inn-fort-worth-medical-center-FTWMDGI/index.html. CHI will work with the hotel to link these reservations.

Date:

Your Name

Address:

Mobile phone number:

Email

Names of people in addition to you in your family attending the conference. Please include children and their ages:

Please indicate which type of room you are requesting:

One King Bed

Two Double Beds

Please state in 200 words or less your reason for seeking this scholarship. Please state your financial need.

Please state in 200 words or less what you hope to gain by attending the conference.

Please authenticate your form submission:

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