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Matthew Harty Camper Fund Scholarship Application

2025 Matthew Harty Camper Fund Scholarship Application

Sponsored by MitoAction

"*" indicates required fields

Name of Applicant*

First Name Last Name

Applicant Address*

Address Line 1 Address Line 2 City State Zip Code

Ethnicity

Primary Language

Pronoun

Applicant Phone*

Applicant Email*

Applicant Birth Date*

Please use the following format: XX/XX/XXXX

Applicant Gender*

What is your mito diagnosis?*

Alpers’ Disease

ACAD9 Deficiency

Autosomal Dominante Optic Atrophy (ADOA)

Barth SyndromeA rare, genetic disorder of lipid metabolism that primarily affects males.

CACT Deficiency

CPEO

Complex I Deficiency

Complex II Deficiency

Complex III Deficiency

Complex IV Deficiency

Complex V Deficiency

CoQ10 Deficiency

CPT I Deficiency

CPT II Deficiency

Creatine Deficiency Syndrome

CUD/Primary Carnitine Deficiency

Friedreich’s AtaxiaFriedreichs Ataxia

GAII/MADD Deficiency

Kearns-Sayre Syndrome (KSS)

Lactic Acidosis

LCHAD Deficiency

Leigh Syndrome

Leukodystrophy

LHON

LHON Plus

Luft Disease

MCAD Deficiency

MCKAT Deficiency

MELAS

MEPAN

MERRF

MIRAS

MitochondrialRelated to the mitochondria. Cytophy

Mitochondrial DNA Depletion

Mitochondrial Encencephalopathy

Mitochondrial Myopathy

MNGIE

M/SCHAD Deficiency

MMDS

NARP

Pearson SyndromeA rare disease that targets the bone marrow and pancreas. Through dysfunction of cells in the bone marrow that produce white and red bloods cells along with platelets.

POLG Mutationsgenetic variant, genetic change

POLG 2

Primary Mitochondrial Myopathy

Pyruvate Carboxylase Deficiency

Pyruvate Dehydrogenase Deficiency

PDCD

SCAD Deficiency

Thymidine Kinase 2 Deficiency (TK2)

VLCAD Deficiency

Undiagnosed

Other

High School Name*

High School Location*

City State

SAT or ACT Score*

GPA*

Please use your most recent GPA

College Name*

College Location*

City State

Degree & Major to be pursued*

Have you previously been awarded the Matthew Harty Scholarship?*

Yes

No

If yes, please list which school year(s) you received the scholarship.*

Transcript/Enrollment Verification

If you have already enrolled for the fall semester, please attach proof of enrollment. This is not required to receive the scholarship, but must be sent before award is issued.

Max. file size: 2 GB.

Physician Letter

If you have a physician letter already, you may upload it here, otherwise, your physician should email it to scholarship@mitoaction.org or fax to (888) 648-6228.

Max. file size: 50 MB.

Extracurricular Activities*

(sports, music, art, work, hobbies, etc.). You may include this as an attachment if necessary.

Extracurricular Activities

Please upload here if needed.

Max. file size: 2 GB.

Volunteer & Community Service Activities*

(especially those that impact children and teens with chronic medical conditions or special needs). You may include this as an attachment if necessary.

Volunteer & Community Service Activities

Please upload here if needed.

Max. file size: 50 MB.

Please include a typed, single-space, one-page essay that addresses the following question:*

How will the Matthew Harty scholarship help you to succeed in college and how has mitochondrial disease affected your life and your education in a way that can help you to be a source of inspiration to others struggling with the disease?

Max. file size: 2 GB.

Please attach a photo of yourself.*

Photo will only be used if you are a recipient.

Max. file size: 2 GB.

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

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