Save my progress and resume later | Resume a previously saved form

Resume Later

In order to be able to resume this form later, please enter your email and choose a password.

Your Email:

A Password:

Confirm Password:

About Your Study

Congratulations on presenting your study, funded by a Grant from The DAISY Foundation. We are happy to send a reimbursement check to your Grant Office to reimburse your expenses from presenting your findings at a professional conference. This grant will provide up to $2,000 for the following specific conference-related expenses: Registration fee to present at a professional conference; Round-trip economy airfare; 2 nights' hotel stay; Transportation to/from the conference city airport (not to/from your home to your home airport); $50 per diem food expense not to exceed $100; Poster production (if poster presentation). Receipts required.

Your Grant Number (if you need to be provided with this number, please email FaithThomas@DAISYFoundation.org):

Has your final report been submitted to the DAISY Foundation?

When do you anticipate your final report will be sent to The DAISY Foundation?

Tell us about the conference you attended

Name of organization hosting conference:

Name of conference attended:

Conference location (city and state):

Dates attended conference (mm/dd/yyyy- mm/dd/yyyy):

First name of person who attended the conference:

Last name of person who attended the conference:

Title of person who attended the conference:

Email of person who attended the conference:

Phone number of person who attended the conference:

Funding Requested

Please provide the following costs that you would like to be reimbursed for and upload the related receipt/ proof of payment.

Final amount requested for conference registration:

Conference Registration Receipt/ Proof of Payment

Final amount requested for 2 nights of hotel:

Hotel Receipt/ Proof of Payment

Final amount requested for round-trip economy airfare:

Airfare Receipt/ Proof of Payment

Final amount requested for transportation to/from conference city airport to hotel:

Transportation Receipt(s)/ Proof of Payment

Final amount requested for food ($50 per diem for 2 days at maximum- excluding alcohol):

Food Receipt(s)/ Proof of Payment

Final amount requested for poster production:

Poster Receipt/ Proof of Payment

Total amount requested:

Check Information:

To whom will the check be written if you are approved? (an institution or a fund at your institution, only. Not to an individual.):

Department/Mailstop/P.O. Box, etc.:

Street:

City:

State:

Zip Code:

Documentation

Please upload a photo of you at the conference here

A scan of the program page on which your presentation is listed

Acknowledgement

By checking this box and submitting the online form, you agree to The DAISY Foundation collecting and storing your personal contact information. We may contact you if we have questions about your submission or to discuss next steps. To learn more, please read our Privacy Policy.

I Agree

Save my progress and resume later | Resume a previously saved form

Contact Information