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To assist us in planning disease-specific sessions and networking activities, please select any conditions that you identify with, either as a patient or caregiver/care partner: (Please check all that apply.) Alpers Disease Barth Syndrome Beta Oxidation Defects Carnitine-Acyl-Carnitine Deficiency Carnitine Deficiency Complex I Deficiency Complex II Deficiency Complex III Deficiency Complex IV Deficiency / COX Deficiency Complex V Deficiency CPT I Deficiency Creatine Deficiency Syndromes Co-Enzyme Q10 Deficiency CPEO CPT II KSS Lactic Acidosis LBSL – Leukodystrophy LCAD LCHAD Leigh Disease or Syndrome LHON Luft Disease MAD / Glutaric Aciduria Type II MCAD MERRF MELAS MEPAN MIRAS MitochondriaL DNA Depletion Mitochondrial Encephalopathy Mitochondrial Myopathy MNGIE NARP Pearson Syndrome POLG Mutations Primary Mitochondrial Myopathy Pyruvate Carboxylase Deficiency Pyruvate Dehydrogenase Deficiency SANDO SCAD SCHAD TK2 VLCAD Other
In order to attend the 2025 Mito Med Conference, I need scholarship assistance for the following: Conference RegistrationAirfareCar/Gas/Tolls (if driving)Hotel
Have you approached other organizations for support to help defray the cost of attending conference? YesNo
If Yes, then please Explain:
Have you previously been awarded any scholarship travel funds by the UMDF? YesNo
If Yes, please explain and provide year(s) you received funding to attend.
Please provide a brief explanation of your financial situation **
Are you currently an active UMDF Ambassador? YesNoNot yet, but interested
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** Regarding financial information question, please include any information that you feel is relevant including any volunteer involvement you have with UMDF and any extraneous expenses you will incur by attending.