Travel Stipend Application

HDU is pleased to offer a limited number of travel stipends, on a first come, first served basis, to patients and care-partners who wish to attend the 2016 Conference “Home Dialysis in Vegas: Beat the Odds”. Only those who truly need financial assistance to attend this year’s meeting will be considered. Applicants’ privacy and submitted information will remain confidential to HDU only. Only completed applications will be considered. Due to the limited number of stipends available, not all submissions will result in an award. Stipend funds cover ONLY the cost of travel to/from the conference location, Las Vegas, and a voucher will be awarded at the time of registration. Any additional expenses must be covered by the attendee. To be considered for a scholarship, applicants must write a short essay on how “Home Dialysis has Changed their Life”, and agree to allow HDU to use these essays in its efforts ot promote Home Dialysis (applicants may choose to have their story remain anonymous if they wish). Applications must be received by September 1, 2016.

HDU Application for $200 Travel Stipend

Name:
Address:
City:
State:
Zip:
Phone:
Email:

1. What best describes your employment status?
Employed full-timeEmployed part-timeSelf-EmployedNot employed, but looking for workNot employedRetiredStudentMilitaryCaretaker/HomemakerOther
If other (please specify)

2. Please provide approximate annual household income:

3. Please let us know if you are a:
PatientCare partner

4. If you are a patient, please indicate what type of patient you are:
Pre-dialysis (CKD Stage 1-4)In-center hemodialysisHome hemodialysisPeritoneal dialysisTransplant recipientOther

If other (please specify)

Please Complete a 500 word Essay on “How Home Dialysis has Changed my Life”: