James Chappell/Carmen Dennis Award  FORM UPDATED 8/3/21

	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 attached application must be completely filled out and submitted to the President of the National Federation of The Blind of Illinois.  Please submit this form in an accessible format, .doc, .docx, .txt, .rtf or an accessible Adobe PDF.  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. 

James Chappell/Carmen Dennis Award Application

APPLICANT:
Name  					Date 

Phone:
Cell:
e-mail:

I am seeking assistance to attend:
( ) Washington Seminar
( ) NFBI Spring Seminar 
( ) National Convention 
( ) State Convention 
Indicate the assistance you need and estimate the amount needed.
( ) Transportation: 		______
( ) Lodging: 			______ covers _____ # of nights.
( ) Meals: 				______
( )  Registration: 		______
( ) Banquet: 			______

( ) other: ____________________________________________
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 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: 

Signature of Applicant:  (You may sign electronically)

RELEASE FROM ALL LIABILITY AND CONSENT FORM
National Federation of the Blind of Illinois 

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.

________________________________________
Print Name of Participant

________________________________________
Print Name of Parent / Guardian (if participant is under 18 years of age)

________________________________________
Signature of Parent / Guardian (if participant is under 18 years old)