Please enable JavaScript in your browser to complete this form.First Name *Last Name *Email *Phone Number *Mailing Address *Address Line 1Address Line 2CityState / Province / RegionPostal Code— Select country —AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia (Plurinational State of)Bonaire, Saint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo (Democratic Republic of the)Cook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Kingdom of)EthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIreland (Republic of)Isle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea (Democratic People's Republic of)Korea (Republic of)KosovoKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesia (Federated States of)Moldova (Republic of)MonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth Macedonia (Republic of)Northern Mariana IslandsNorwayOmanPakistanPalauPalestine (State of)PanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyrian Arab RepublicTaiwan, Republic of ChinaTajikistanTanzania (United Republic of)ThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUgandaUkraineUnited Arab EmiratesUnited Kingdom of Great Britain and Northern IrelandUnited States Minor Outlying IslandsUnited States of AmericaUruguayUzbekistanVanuatuVatican City StateVenezuela (Bolivarian Republic of)VietnamVirgin Islands (British)Virgin Islands (U.S.)Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland IslandsCountryWhat is your connection to leukodystrophy? *Person with leukodystrophyParent of a child with leukodystrophySpouse or partner of a person with leukodystrophySibling of a person with leukodystrophyExtended family member of a person with leukodystrophyFriend of a person with leukodystrophyMedical Professional or Care Team MemberResearcherPatient Advocacy Group RepresentativeIndustry RepresentativeStudentOtherPatient Advocacy Organization Name:Company Name:OtherWhich type of leukodystrophy affects you or your family member? *Are you or your loved one newly diagnosed? *YesNoPlease specify the year you or your loved one received the diagnosis.Have you attended the ULF Family Conference previously? *YesNoWhat year(s) did you attend the ULF Family Conference?Have you received a scholarship or financial assistance from the ULF previously? If yes, which year(s)? *Will you be attending the conference with any guests? *YesNoPlease provide your guest(s) full name(s)? If child(ren) is 17 years or under please include their age.For children attendees: Ages are collected to ensure we can offer age-appropriate activities in the Kids Room (ages 4–12) and the Teen Program (ages 13–18). If you prefer not to share your child(ren)’s age, please enter N/A.Household Income: *$0 – $25,000$25,001 – $50,000$50,001 – $75,000$75,001 – $100,000$100,001+Statement of Financial Need: *Please explain why attending the Family Conference would be a financial challenge for your family. Scholarships are intended to support families experiencing financial need.Are you willing to provide a post-conference testimonial or participate in a follow-up survey? *YesNoScholarship Guidelines Agreement *I have read and agree to the Scholarship Guidelines provided on this page: https://ulf.org/2025-family-conference-scholarships/By submitting this form, you agree to complete any necessary follow-up documentation or forms required to facilitate your attendance at the conference within the timeframe provided by ULF. Submit
