ALDAcon 2021 Scholarship Application Application for ALDAcon 2021 Scholarship Date MM slash DD slash YYYY Name First Last Nickname for ID badge Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email* Are you an ALDA Inc. member? Yes No Are you a member of an ALDA Chapter or Group? Yes No If so, which one? Please briefly describe your involvement in ALDA Either ALDA Inc. or chapter or group (e.g. are you a board member? Do you attend meetings?Please tell us your hearing status: Deaf Late deafened Hard of hearing Hearing Have you ever attended an ALDAcon?* Yes No If yes, which year(s)/location(s) Preference is always given to first time attendees.Have you ever previously received scholarship funds to attend an ALDAcon?* Yes No If yes, which year? What did your award cover? If you have previously applied but did not attend, please briefly explain.Please tell us briefly why you want to attend ALDAcon.*Please describe the kind(s) of financial assistance you feel you need to attend ALDAcon* Full Registration Partial Registration Hotel - (1/2 of shared room) Please select the amount of help in each area you would need (e.g. Full Half?) NOTE: Scholarship funds cover a shared room only; help will be provided for roommate matching. Transportation costs are not provided in scholarship awards.To help us in our decision making, please briefly describe the financial reasons you are applying for help.*Deadline for application submission is June 30, 2021Acknowledgement of your application will be sent to you immediately upon its receipt. If you do not hear from us within a day or two of submitting your application, please get in touch with us. You will get a response from ALDA's Scholarship Committee regarding your application no later than the second week of July. Please include any additional information that you feel will be helpful to us in making a decision regarding your application.Special NeedsPlease check boxes that apply for your special needs if you are selected None Mobility accessible room needed ADA kit requested Dietary Restrictions or Allergy - see below Dietary NeedsIf you checked Dietary restrictions above, please briefly list your allergy or restriction. i.e., gluten-free, diabetic, etc. Questions or concerns regarding scholarship and applications may be sent to:If you have any questions or if you do not receive a confirmation of receipt of your application within three days, please contact the ALDA Scholarship Committee Chair, Karen Krull, at email@example.com.