Phoenix Society World Burn Congress and ABA Conference Scholarship Application

Phoenix Society World Burn Congress and ABA Conference Scholarship Application

For questions concerning the Phoenix Society or the World Burn Congress, additional information is at phoenix-society.org. If you have questions regarding the application please email Mary.Houston@luhs.org.

First Name

Last Name

Email Address

Home Address

City

State

Zip

Date of Birth

Role within Burn Community

Burn Survivor

Family Member

Medical Professional

Other

If you selected Medical Professional or Other, please describe:

Number of Additional Attendees

Additional Attendees

Parent / Legal Guardian

Other Family Member

Additional Attendee: First Name

Additional Attendee: Last Name

Additional Attendee: Email

Additional Attendee: Home Address

Additional Attendee: City

Additional Attendee: State

Additional Attendee: Zip

Additional Attendee: Date of Birth

Emergency Contact: Name

Emergency Contact: Phone Number

Have you attended a previous World Burn Congress?

Yes

NA- ABA applicant

If Yes, have you previously received financial assistance from the Phoenix Society to attend Phoenix World Burn Congress?

Yes

NA - ABA applicant

Can we share your name and story in our communications (flyers, website, donor letters, etc.)?

Yes

Please use the space below to articulate why you want to attend the World Burn Congress or ABA.

I certify that the information provided above is accurate.

Yes

Applicant Digital Signature

Please type your full name for confirmation.

Signature of Parent/Legal Guardian

Please type full name if the applicant is a minor.

Send me a copy of my responses

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