Travel Scholarship

Travel Scholarship

As part of the Odone Family Support Program, The Myelin Project provides travel stipends for patients in the United States wanting to travel to ALD & AMN specialists and/or patient events and/or scientific conferences.  Travel stipends range from $250-$750 and are intended to help offset travel costs but not to cover all costs in full. The amount of the award depends upon the distance the recipient has to travel for the event or doctor visit.

By submitting this application, you affirm that the facts set forth in it are true and complete. If you are accepted as a scholarship recipient, any false statements, omissions, or other misrepresentations made on this application may result in my immediate disqualification. If you have any questions or comments regarding the application process, please contact us.  Send any additional attachments to info@myelin.org.

First Name

Last Name

Address

City

State

ZIP

Email

Phone Number

Patient Name

Your Relation to Patient

Purpose of Travel

Please attach a photo of patient and/or applicant

Patient Diagnosis
 Adrenoleukodystrophy (ALD) Adrenomyeloneuropathy (AMN) Unknown Leukodystrophy

Please attach documentation proving your and/or your family member's diagnosis of ALD or AMN.

Patient's Date of Birth

Patient's Race/Ethnicity
 African-American Asian Caucasian Hispanic/Latino Native American Native Hawaiian Other

Total Annual Household Income
$ .00

Total Annual Public Assistance (e.g. Social Security, Disability, etc.)
$ .00

Please attach proof of income (e.g. pay stub, W-2, and/or income tax return)

(Note: .PDF format only)

Neurologist/Pediatrician

Medical Insurance

Please write a short statement about how ALD and/or AMN affect(s) your life and/or your family member(s), and how this travel scholarship could help you and/or your family member.

How did you hear about us?

 I understand that the information I am giving will be verified by the The Myelin Project, state and/or federal enforcement agencies and others as required. I certify that the above information is true and accurate to the best of my knowledge.