Colorectal Cancer Alliance
AllyCon 2022 Scholarship Application Form

First Name

Last Name

Mailing Address

City

State

Zip Code

Phone

What is your Connection to Colorectal Cancer?

If Patient/Survivor, what is your treatment status?

If Patient/Survivor, what stage are you now?

Total number of Alliance conferences you have attended?

Would you like to join us for Allies in Action on Day 1 of AllyCon 2022 so you can meet with other allies from your region to imagine increasing support locally? Based on your experiences and knowledge of your community, you will brainstorm about increasing local screening, support for CRC patients, their families, and partnership with the medical community.

YesNo

Travel and Registration Scholarship Requirements

We are pleased to offer a limited number of scholarships for those with financial need. Scholarship requirements:

For a single household: total yearly household income equal to or under $30,000.
For households with two or more: total yearly household income equal to or under $50,000.
Willing to provide proof of the above income requirements.

I would like to apply for a travel scholarship of up to $500.

I would like to apply for a registration fee scholarship that will reduce my registration fee to $50.

Please describe why you are in need of a scholarship to attend AllyCon 2022, including details about your household income.

Terms and Conditions

The following terms and conditions apply:

Scholarships will be limited to patients, survivors, caregivers, and family members.
Applicants must live in the United States.
Scholarship awards will be made on a first-come, first-served basis of financial need.
Scholarship recipients are expected to attend all Colorectal Cancer Alliance AllyCon 2022 events and sessions.
Scholarship recipients agree to provide a quote to the Colorectal Cancer Alliance within 10 days after the conference regarding their experiences for use in reports and future promotional materials.
Scholarship recipients agree to waive any and all claims or causes of actions against the Colorectal Cancer Alliance, for any injuries or damages that may occur in any way related to the conference including travel, attendance, or lodging.

By submitting this application, I understand I may be photographed and/or submit photographs, video and other media content to be used for educational, archival, and public relations purposes by the Colorectal Cancer Alliance.

Yes, I want to receive email updates from the Colorectal Cancer Alliance.Yes, I want to receive periodic text updates from the Colorectal Cancer Alliance. Message and data rates may apply. Text STOP to opt out, HELP for info. Privacy Policy.

Contact Information

Colorectal Cancer AllianceAllyCon 2022 Scholarship Application Form

Colorectal Cancer Alliance
AllyCon 2022 Scholarship Application Form