Scholarship Application

KS&A is a non-profit education and support organization, dedicated to disseminating the latest scientific information and support resources concerning X and/or Y chromosome variations including XXY, Klinefelter syndrome, Trisomy X, XYY and associated conditions to all people, regardless of background.  If you or anyone you know has a desire to learn about these conditions through our DVDs, conference materials or by attending a scheduled event for which there is a fee, but cannot afford to do so, we have provided the KS&A Scholarship Fund to enable everyone to access this information and improve their lives.

All applicants will be contacted by a representative of KS&A within 4 weeks of receipt.  Approval of each scholarship request is dependent on the availability of adequate funding to respond to the request, and is based upon need.  Preference will be given to affected adults and adolescents, and families of affected children.  Please note that if you decide to pay for an event or DVD and then you are subsequently approved for a scholarship, your money will not be refunded.

If you would like to apply for a scholarship, please provide us the followng information…

First Name
MI
Last Name
Address 1
Address 2
City
State
Postal Code
Country
Daytime Phone
Evening Phone
Preference
Email Address
  
Type of Assistance Requested (Check all that apply)





  
Please describe the DVD/printed material/event you would like to receive (for events, please list the event name, location and date; for DVDs and printed materials, please state the exact titles and format) -
  
What condition are you most interested in?




  
What age is the affected individual with this condition?
  
Please describe your relationship to this individual, or if you are applying for yourself, enter "Self" below -
  
Please explain in as much detail as possible why you feel you are unable to personally purchase the above item (attach an additional page if necessary) -
  
I understand that my sole obligation by accepting this scholarship is to assist someone else when I am next in a position to do so.  Please be advised that by signing this application, you give KS&A permission to use your story to inspire others to give to the KS&A Scholarship Fund. 
  
Digital Signature
Date
  



Published on Mar 04, 2007 at 11:17 AM
Last updated on Mar 12, 2007 at 08:28 PM
KS&A, 11 Keats Court, Coto de Caza, CA 92679
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Disclaimer: The information presented on this site is not intended as a substitute for professional medical advice. Don't use this information to diagnose or develop a treatment plan for a health problem, disease or condition without consulting a qualified health care provider. If you are in a life-threatening or emergency medical situation, seek medical assistance.

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