Scholarship Application Form

ACADEMIC YEAR - Indicate the academic year for which you are applying for scholarship assistance.

Freshman Sophomore Junior Senior
College/University:
PERSONAL DATA
First Name			MI	Last Name DOB

Permanent Street Address Line 1				Permanent Street Address Line 2

City	State	Zip	Phone		Permanent e-mail

Street Address at School Line 1				Street Address at School Line 2

City	State	Zip	Phone at school		e-mail at school

How did you hear about us?

Describe yourself in one paragraph

Describe your family situation in one paragraph

Yes. I am willing to do volunteer work, share my experience with young patients with cancer or other medical challenges and provide them emotional support and guidance.

Have you previously performed volunteer work? If you did, please give details.

EDUCATION

High School	College/University for Academic Year Indicated

Location (City, State)	Location (City, State)

High School GPA	College GPA

Major Subject	Degree Expected	Expected Year of Graduation

MEDICAL INFORMATION

Yes. I have been diagnosed with cancer.

Name of your Attending Physician	Name and Location of Hospital

Type of Cancer	Age Diagnosed

FINANCIAL INFORMATION

Expected expenses for academic year indicated		List any other scholarship assistance applied for
Tuition, Fees and Books
Room, Board & Transportation
Other
TOTAL
Family Income (To be Verified)

SUPPLEMENTAL INFORMATION

Please mail the following documentation to:

Cancer Survivors' Fund

P.O. Box 792, Missouri City, TX 77459

	Two (2) letters of recommendation from two different academic teachers addressing why you should receive this scholarship.
	A letter from your attending physician verifying your medical history and current medical situation.
	A copy of an acceptance letter from the college/university of your choice or a letter of good standing from the registrar.
	A release from you, and your parents if you are a minor, that you agree to have your name and photo published in the news media or any CSF publication as a recipient of Cancer Survivors' Fund scholarship and that you agree to have your name, photo and your success story to be published on this website or in any CSF publication.
	A 2.5 x 3.5 portrait photo (digital preferred).

Download Release

Completed applications and supporting documents must be submitted by March 24th to be considered for the 2009 Fall Semester. Late applications will be considered for the next semester.

Please DO NOT print and mail this application or the essay. Use the Submit Application button below.

THE ESSAY

Submit an essay with this application. Discuss the following question. HOW HAS MY EXPERIENCE WITH CANCER IMPACTED MY LIFE VALUES AND CAREER GOALS? Essays must be a minimum of 500 words and a maximum of 1200 words. Essays may be entered in the box below or submitted separately, attached to an e-mail. Please DO NOT mail.

Last Name