QUEER DISABILITY CONFERENCE 2002 -- SCHOLARSHIP FORM

(Please note that the QD conference organizers use email as our primary mode of communication. Therefore, please give us your most reliable, frequently-checked email address.)

Name:

Email address:

Title:

Organization or institution:

Mailing address (optional):

Street:
City:
State:
Zip:

Phone number (optional): (Voice or TTY?)
Fax number (optional):

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FOR HOUSING ASSISTANCE
Housing costs are $28/nite for a shared double room, and $50/nite for a single room.
How many nights will you stay:____ Single or double: ____ What can you pay? ______

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FOR TRAVEL ASSISTANCE
What are your travel costs:____
What can you pay? ______

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I need a scholarship so I can bring an attendant: ___yes ___no

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Please print this and mail it to:
QD/DWA Scholarship
PO Box 6008
Albany, CA 94706

QUESTIONS?: QDConference2002@hotmail.com