James Chappell/Carmen Dennis Award Application Form

This award has been established as a living memorial to James Chappell and Carmen Dennis. James and Carmen were both long-time Federationists with extraordinary dedication to our movement.

James’ hard work on behalf of the National Federation of The Blind (often in the face of seriously impaired health) was an inspiration and a demonstration of undaunted loyalty and dedication to the organized blind movement. James passed away on the steps of City Hall on his way to advocate for better transportation.

Carmen served our affiliate in numerous capacities throughout the years. She often assisted people to attend conventions out of her own pocket. She passed away while she held the office of NFBI secretary.

The award is intended to assist persons interested in NFBI to attend conventions, seminars, and the like. Recipients of the Chappell/Dennis Award must demonstrate genuine interest in, and commitment to the blind of Illinois or the potential to develop such interest and commitment. Recipients are expected to attend all sessions relative to the event for which they receive assistance.

The NFBI expects all participants to contribute to funding to attend events. The Award Committee may award partial funding to assist individuals to attend seminars, conventions, or the like.

All required fields are marked with a *.

Applicant Name

First Name First Name

Last Name Last Name

Street Address Street Address

Street Address Line 2 Street Address Line 2

City City

State/Province State/Province

Postal Code Postal Code

Phone Number Phone Number

Cell Phone Number Cell Phone Number

Email Email

Date of Birth Date of Birth

Date of Birth Date of Birth

I am seeking assistance to attend I am seeking assistance to attend

Indicate the assistance you need and estimate the amount needed.

Transportation Assistance Transportation Assistance

Estimated Amount Estimated Amount

Lodging Assistance Lodging Assistance

Estimated Amount Estimated Amount

Covers how many nights? Covers how many nights?

Meal Assistance Meal Assistance

Estimated Amount Estimated Amount

Registration Assistance Registration Assistance

Estimated Amount Estimated Amount

Banquet Assistance Banquet Assistance

Estimated Amount Estimated Amount

Other Assistance Other Assistance

Estimated Amount Estimated Amount

I expect my costs for the above to be approximately I expect my costs for the above to be approximately

$

NFBI reserves the right to reduce or eliminate any award based on a change of plans by the applicant. For example, if you indicate that you will stay 5 nights and change your plans to stay less time, NFBI may require repayment of all or a portion of the award.

Indicate any other sources for funding you have applied to, including Chapters of NFBI Indicate any other sources for funding you have applied to, including Chapters of NFBI

Indicate any other sources for funding you have applied to, including Chapters of NFBI
	Indicate any other sources for funding you have applied to, including Chapters of NFBI Indicate any other sources for funding you have applied to, including Chapters of NFBI	Item weight Item weight

Add more items

more items

Indicate Federation activities in which you have been involved, including but not limited to conventions, seminars, fund raising, legislative action, and chapter membership Indicate Federation activities in which you have been involved, including but not limited to conventions, seminars, fund raising, legislative action, and chapter membership

Indicate positions of leadership you have held Indicate positions of leadership you have held

RELEASE FROM ALL LIABILITY AND CONSENT FORM

If the applicant is under age 18 at the time of the event, a parent or guardian must sign a release. This ensures that all under aged applicants have parental permission to attend the event and submit this application.

By signing my name below, I agree to assume all risks and to release, hold harmless, and covenant not to sue the National Federation of the Blind or any designated beneficiaries, sponsors, officers, officials, affiliates, chapters, communities, organizations, friends of the event, and all other government or public entities and all their respective directors, officers, agents, employees, and members for any claim, loss, or liability that I may have arising out of my participation in the event.

I / My child will participate in the event facilitated by the National Federation of the Blind of Illinois. I / My child will adhere to any and all rules and policies of the Program. I agree / My child has permission to participate in all activities of the Program.

Signature of Applicant

Participant's Name Participant's Name

Parent / Guardian's Name (if participant is under 18 years of age) Parent / Guardian's Name (if participant is under 18 years of age)