HCMA Patient Weekend Scholarship

First Name *

Last Name *

Email *

Address Line 1 *

Address Line 2

City *

State/Province *

Zip/Postal Code *

Country *

Relationship to HCM *

Patient

Parent

Caregiver

Spouse

Donor

What type of assistance are you requsting? Check all that apply *

Hotel accommodations ($199 per night)

Patient Meeting Registration ($50)

Patient Meeting Reception ($30)

5K registration ($45)

Flight (please reach out to Angel Flight East directly)

Is your family household income less than three times the poverty level? ( $40,770 for a family of 1; $54,930 for a family of 2; $69,090 for a family of 3; $83,250 for a family of 4; $97,410 for a family of 5; $111,570 for a family of 6)

Yes

No (if no, please answer the question below regarding need)

My family income is NOT less than three times the federal poverty level, but I have the following extenuating financial circumstances. (Please provide information)

Please briefly explain why you are requesting financial support to attend. *

Please share a few sentences describing your current situation and what attending this meeting would mean to you.

Data Privacy & Consent

Yes, I would like to receive communications from Hypertrophic Cardiomyopathy Association by email.

Yes, I would like to receive communications from Hypertrophic Cardiomyopathy Association by phone.

Yes, I would like to receive communications from Hypertrophic Cardiomyopathy Association by mail.

Yes, I would like to receive text messages from Hypertrophic Cardiomyopathy Association Because I have a big heart! Lisa and the team, thank you!

Yes, I consent to have Hypertrophic Cardiomyopathy Association share my data with a third-party service.