Andy M. Cahn Advocacy Scholarship application

Andy Cahn Advocacy Scholarship Application

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Name *

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Last

Address *

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Please describe (1) Your current involvement with the Alzheimer’s Association, including chapter activities you have participated in and the length of time you have been involved. (2) Your reasons for wanting to attend the AIM Advocacy Forum and (3) How you plan to remain active in Alzheimer’s advocacy after the forum: *

Please read the following statements and indicate your agreement by checking the boxes: *

I understand that, if selected for a scholarship, I am expected to attend all three days of the AIM Advocacy Forum in Washington, D.C., which runs from June 17 through June 19, 2018. I understand that, in order to attend the AIM Advocacy Forum, I must be a member of AIM and that the AIM membership fee of $20 will not be reimbursed by the Alzheimer’s Association. I understand that, if selected for a scholarship, I am expected to participate in two meetings at my member of Congress’s local office — one prior to the forum and one after the forum. I understand that funds will be reimbursed upon submission of receipts for forum-related expenses, up to a maximum amount of $1,000. I understand that in the event I am unable to attend the forum after being awarded a scholarship, I must notify the Alzheimer’s Association Hudson Valley Chapter no later than noon on May 18, 2018, and will be expected to repay any monies already paid out.

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