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Relationship to child affected by CMV (select one)

Has another member of your family (immediate or extended) applied for a scholarship for the 2018 conference?
If yes, please provide their name.

Without scholarship funds, I would be unable to attend the 2018 CMV Public Health and Policy Conference.


 

 I provide permission for my story and pictures to be shared at the conference and in other CMV conference and awareness materials developed by the conference and its sponsors.

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 If I receive a scholarship, I agree to attend 2018 CMV Public Health and Policy Conference. If I do not attend the conference, I am responsible for returning my scholarship funds to the National Center for Hearing Assessment and Management.

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