2025 Family Retreat Financial Assistance Request

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Name

First

Last

Address

Phone

attend retreat the

Name of person with Neutropenia

Age of Person with Neutropenia

What type of Neutropenia has been diagnosed?

What year was diagnosis made?

Have you ever attended a Neutropenia Retreat (aka Conference)

Please enter the name of each adult wanting to attend the retreat.

Please enter the name(s) and age(s) of each child you would like to attend.

Please advise which discount you are requesting.

$50 Registration Discount (you may submit after this selection, no need to answer next section questions)
Hardship Grant (Requesting assistance above the discounted rate)

If requesting Hardship Grant, please give a summary of your/the patient's neutropenia health history.

We are looking for an overall picture of the kinds of issues the patient has been dealing with, health, emotion, etc.

If requesting Hardship Grant, please give a summary of your financial situation as it relates to your ability to attend the conference.

If requesting Hardship Grant, please provide a statement on why attending the retreat is important to you.

You can also use this space to add anything else that you would like to add that may be of relevance, such as how you feel your family/yourself will benefit.

Terms & Conditions

I agree

I agree to allow the National Neutropenia Network to store the data I am submitting so that they may respond to my application.