The Southern California Youth HDSA-LA 2013 Annual Convention Scholarship
Dear HD Families and Friends,
The Huntington’s Disease Society of America is hosting the 28th Annual Convention in Jacksonville,
Florida from June 21-23, 2013. We at HDSA-LA are pleased to announce the creation of a financial aid
scholarship for young adults (21yrs. of age and under) living in Southern California who are affected by
Huntington’s disease who wish to attend the Convention. We are accepting applications through Friday,
May 10th, 2013. Final awards will be made by Friday, May 17th and all applicants will be promptly notified
on the status of their application thereafter.
This Fund was established to benefit families affected by Huntington’s Disease and exists because of the
support and generosity of the Goodwin Family Memorial Trust.
Scholarship Availability & Application

The scholarship is open to any young adult (21yrs. of age and under) living in Southern California
who is affected by Huntington’s disease.

All scholarship recipients are required to attend the Convention events beginning on Friday, June
21 and ending on Sunday, June 23.
What does the scholarship cover?

A Full Scholarship: A full scholarship recipient will receive funding to cover hotel accommodations
(you may be asked to share a room with other scholarship recipients); Convention registration, which
includes your ticket to the Gala dinner on Saturday; a nominal amount of assistance for food during
the Convention and gas money/airport transportation at 0.55 cents per mile to and from the hotel.

A Partial Scholarship: A partial scholarship may be awarded when the total amount of funds in the
overall scholarship fund will not allow for a full scholarship. Any person may also request a partial
scholarship if they are able to pay for some portion of their costs and only require partial assistance.
Application Deadline: Applications must be received no later than midnight, Friday, May 10.The
application and required documents are to be scanned to Natalie Carpenter at ncarpenter@hdsa.org or
mailed to:
Natalie Carpenter
Pacific Southwest Regional Development DirectorHuntington’s Disease Society of America
27702 Crown Valley Pkwy
Suite D-4 #336
Ladera Ranch, CA 92694
Phone (949) 542-3907
We look forward to working to make your HDSA Annual Convention experience a positive one!
The Southern California Youth HDSA-LA 2013 Annual Convention Scholarship
Application
This, and all following pages, must be completed and submitted to HDSA Pacific Southwest Regional
Development Manager as your “application” for the Southern California Youth HDSA 2013 Annual
Convention Scholarship. The application may be completed by any young adult (21yrs. of age and under)
living in Southern California who is affected by Huntington’s disease who needs financial assistance to
attend the HDSA 2013 Annual Convention in Jacksonville, Florida. The Scholarship Review Committee
will keep all information contained on this application in strict confidence, and you will be notified by the
HDSA Pacific Southwest Regional Manager of your application status upon review of applications and
available funds.
Deadline: 11:59 p.m. on Friday, May 10, 2013
Determination of Scholarship Awards: The scholarship awards will be determined by the HDSA-LA
Scholarship Committee based on financial need, previous Convention attendance, location and the
applicant’s essay. Final awards will be made by Friday, May,17 and all applicants will be promptly notified
on the status of their application thereafter.
Applicant (all fields are required, no P.O. boxes please)
Name:
Street Address:
City:
Home Phone:
Email Address:
Birth date:
State:
Cell Phone:
Zip:
If you are applying as a family, only one application is required. Please list the names and ages of all
family members that are applying below.
Name of other family members attending
Age
Sections 1 through 6
1. Previous attendance at a HDSA Annual Convention:
____ I have never attended a Convention before.
____ This will be my 2nd Convention.
____ This will be my 3rd Convention.
____ I have attended 3 or more Conventions.
2. I have attended local:
____ HDSA fundraisers
____ State conventions
____ HDSA Support groups
____ I am new to HDSA and this would be my first event
3. Are you active in any local HDSA Chapter/Affiliate and/or support groups
_________ Yes
_________ No
If yes, please provide the name of the Chapter/Affiliate and/or support group:
_________________________________________________________________
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Application Deadline: Applications must be received no later than midnight, Friday, May 10, 2013.The application and required documents are to be scanned to
ncarpenter@hdsa.org or mailed to:
Natalie Carpenter
Pacific Southwest Regional Development DirectorHuntington’s Disease Society of America
California/Nevada/Utah/Arizona Region
27702 Crown Valley Pkwy
Suite D-4 #336
Ladera Ranh, CA 92694
Phone (949) 542-3907
4. Essay – “What do you hope to obtain from attending the HDSA Annual Convention?”
Please write and attach to your application an essay on “What do you hope to obtain from attending the
HDSA Annual Convention”? This essay should be a minimum of 200 words and not to exceed 500 words.
It must be returned with your application for scholarship. You can have someone in your family help you
write your essay. Please provide any information about your personal involvement in supporting
Huntington’s disease advocacy, awareness, education, or fund raising efforts either through an HDSA
Chapter or Affiliate, support group, local or national media, etc.
5. Type of Financial Help Needed: Complete this section and return it with your application. It will
help us better understand the financial support you’ll need to attend the HDSA Annual Convention.
As a scholarship winner, I’ll need help with (check what you will need help with):
________ Full Scholarship: including funding to cover hotel accommodations (you may be
asked to share a room with other scholarship recipients); Convention registration, which includes
your ticket to the Gala dinner on Saturday; a nominal amount of assistance for food during the
Convention and gas money at 0.55 cents per mile to and from the hotel.
_________ Partial Scholarship: check partial when you only need assistance with the individual
items checked below.
_________ Hotel room: (3 nights) in Jacksonville, Fl
_________ Airfare: round trip airfare to Jacksonville, FL
_________ Convention Registration: fee including a ticket to the Gala dinner.
__ Nominal Assistance: with meals during the convention.
6. Financial Need: The total 2012 Gross Annual Income for my household was:
Adjusted Gross Income is line 44 on IRS Income Tax form 1040.
____ Under $10,000
____ Over $10,000 but under $30,000
____ Over $30,000 but under $50,000 ____ $50,000 or higher
7. Sections I and II Require Signatures Where Applicable
I – Proof of Financial Hardship
A member of your HDSA Chapter or Affiliate, a social worker, your physician or a clergy person should
sign this. This person is attesting that you require financial assistance in order for you to attend the
Convention.
Financial Witness
I, (print name) ________________________________________________________
I represent (HDSA Chapter/Affiliate, Clergy, etc.):_____________________________
Street Address ________________________________________________________
City/State/Zip__________________________________________________________
Phone _______________________________________________________________
Email: _______________________________________________________________
I hereby attest that the above applicant requires financial support in order to attend the HDSA 2013
Annual Convention.
Signature of Witness: __________________________________________ Date: _____________
II – Release of Liability Applicants 18 and Over: I hereby accept full responsibility for my own safety
and care should I be awarded an HDSA-LA 2013 Annual Convention scholarship. I am able to travel on
my own and attend the HDSA Annual Convention in Jacksonville, FL without aid or supervision.
Signature of Applicant: _________________________________________ Date: ______________
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Application Deadline: Applications must be received no later than midnight, Friday, May 10, 2013.The application and required documents are to be scanned to
ncarpenter@hdsa.org or mailed to:
Natalie Carpenter
Pacific Southwest Regional Development DirectorHuntington’s Disease Society of America
California/Nevada/Utah/Arizona Region
27702 Crown Valley Pkwy
Suite D-4 #336
Ladera Ranh, CA 92694
Phone (949) 542-3907