Dystonia Advocacy Day Scholarship Application – National Spasmodic Dysphonia Association

Thank you for your interest in attending Dystonia Advocacy Day and Training! Please complete all fields below and submit this form for review.

Name*
Prefix First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
Have you ever attended a Dystonia Advocacy Day?
- Yes
- No
Please share your connection to spasmodic dysphonia? (i.e., I have it, I am a family or friend of someone who does, etc.)
Briefly describe why you believe advocacy is important for the SD/dystonia community.
Please share any previous experience with advocacy and/or why you would like to be part of this event?
Are you able to attend Dystonia Advocacy Day and Training in Washington DC?
- Yes
- No
I would need a travel scholarship for:
- Transportation
- Hotel
Additional Comments:
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