Kathy Stagni Deb Lee Gould

Name_______________________________________________Date___________________________
Address________________________________City_______________________Zip________________
E-mail_______________________________________________Phone__________________________
Child’s/Adult’s Name___________________Birthdate_____________Disorder___________________________
The FOD Family Support Group and Organic Acidemia Association have a limited number of partial scholarships available to
assist families in attending our National Conference in Portland, OR. Scholarships will be awarded based on a first come
basis and demonstrated financial need. Please submit the application to Deb Gould for FOD Families and Kathy Stagni
for OAA Families.
Have you attended a past FOD/OAA Conference? If so date and location? ____________________________
Did you receive a scholarship? Yes __ No __ Amount $______
What do you hope to gain in attending the 2012 FOD/OAA Conference?
What is your total anticipated cost for your family to attend this conference? $_________________
What dollar amounts of assistance you are seeking from FOD/OAA? $___________
Please note with the generosity of our sponsors, FOD Group/OAA will be able to provide partial assistance in
travel and hotel. All scholarships will be done on a reimbursement basis upon the completion of the
conference. A maximum of $500 per family will be awarded.
Please sign here to indicate that, if you receive a scholarship to attend the 2012 Conference, you will commit to
active participation, which includes attendance at all keynote and breakout sessions, completion of the program
evaluation and proof of travel for the meeting. If you are emailing this document, please write your name in place
of your signature.
Signature____________________________________________Date:____________________________ Kathy Stagni
Deb Lee Gould
Kathy Stagni, Director
Organic Acidemia Association
th
13210 35 Avenue North
Plymouth, MN 02048
(763) 559-1797
www.oaanews.org
[email protected]
Non Profit Tax ID #48-1038050
Deb Lee Gould, MEd, Director
FOD Family Support Group
PO Box 54
Okemos, MI 48805
(517) 381-1940
www.fodsupport.org
[email protected]
Non-profit Tax #83-0471342