Scholarship Form

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Scholarship Form

*First Name:

*Last Name

*Address:

*City:

*State:

*Zip:

*Country:

Phone # (List preference)

Voice
Captioned Phone
Cell - text only
VP

Phone #:

*E-Mail:

Valid e-mail is required

*Are you an ALDA Inc. Member?

Yes
No

Are you a member of an ALDA chapter or group?

Yes
No

If so, which one?

Describe your involvement In ALDA Inc or chapter/group:

Attend meetings? Board?

Please tell us your hearing status:

Deaf
Late-deafened
Hard of hearing
Hearing

*Have you ever attended an ALDAcon?

Yes
No

*Have you ever previously received scholarship funds to attend an ALDAcon?

Yes
No

If yes, which year?

If yes, what did your award cover?

Please describe the kind of financial assistance you feel you need to attend ALDAcon. Please note that scholarship funds cover a shared room only; Help will be provided for roommate matching.

Please tell us briefly why you want to attend ALDAcon?

Please briefly describe the financial reason(s) why you are applying for help:

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