ASPN Named Travel Award Donor Form

Thank you for your interest in supporting pediatric Nephrology Trainees by establishing a named American Society of Pediatric Nephrology Trainee Travel Award. These Awards will provide trainee travel grants to important educational venues related to pediatric nephrology. Awards may be established in your name or in the name of someone whom you wish to honor. Named Travel Awards will be prominently featured in all appropriate society publications. Trainees will be encouraged to acknowledge the award in their CV. Donors, if so interested, are encouraged to meet and mentor the trainees who receive their grant. Please contact Connie Mackay, ASPN Executive Director with any questions at the number above or Connie@aspneph.org.

Donor Name

First Middle Last Suffix

Phone

Award Name for Publication

(Examples: The Smith Family Travel Award; The John C. Smith Travel Award)

Award Length

Three Year Award – $3,000

Five Year Award – $5,000

Payment

Please enter credit card information below or mail a check payable to ASPN Foundation to the address: 6728 Old McLean Village Drive, McLean, VA 22101

Payment option

I wish to pay in full at this time

I wish to pay in installments $1,000 per year (Payments will be due each year on the anniversary of establishment of the award)

Name on Credit Card

Credit card number

Expiration:

CVV Code

Please enter a number from 001 to 9999.

Billing Zip Code

Billing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

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ASPN Named Travel Award Donor Form

ASPN Named Travel Award Donor Form

Payment

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