Application for the 2023 LIFE Scholarship Foundation, Inc. Program Applications will be accepted beginning June 1, 2023. The deadline to apply for the program is August 31st. Applications postmarked after this date will not be considered. NO EXCEPTIONS. Purpose: The purpose of LIFE Scholarship Foundation, Inc. is to create higher education opportunities for cancer patients and/or survivors and their families by providing financial support to attend accredited colleges and universities within the United States of America. Under the 2023 program, at least four (4) $2,500 scholarships will be awarded. The award(s) may be increased depending on the availability of program funds. The awards will be distributed in August-September 2023. Note: Applicants related to a member of the Board or an employee of the organization are not eligible for the program. Applicants Must: Be a cancer survivor or current patient or has a parent (or guardian) that is a cancer survivor or patient currently residing in the following states: NY, NJ, FL, CA, HI; Be between the ages of 18-35 (an exception may be made if the applicant is 17 and entering college in the Fall 2019 semester); Have been accepted as a full-time student at an accredited college or university within the U.S; Have a GPA of 2.5 or higher on a 4.0 scale; Be a citizen or legal permanent resident of the United States; Purpose: Completed application form;Completed fromMost recent official high school or college transcript;Two (2) personal or academic reference letters (from someone outside your family);Personal essay;Proof of acceptance and enrollment at an accreditedcollege or university within the U.S.Personal Video (up to 3 minutes) that will show us who you are and/or who do you aspire to be (you can attach the video document with your application or provide a personal/public link for us to access it) Download Form *Personal Essay: Submit a personal statement of at least 500 words answering one of the following: How have you used or plan to use your cancer experience to impact the lives of others affected by cancer? Describe how your experience with cancer has impacted your life and the pursuit higher education. Personal Information (Section A): Full Name: Nickname (Preferred Name): Date of Birth: Current Age: Gender: MaleFemaleOther Email Address: Phone Number: Mailing Address: City: State: Zip Code: Secondary/Emergency Contact: Full Name: Relationship to Applicant: Phone Number: Email Address: Address: City: State: Zip Code: How Did You Hear About Us? InternetFamily/FriendEmailSocial MediaSchool Counselor Medical Information (Section B): Name of Cancer Patient: Relationship: Parent (Or Guardian): Type of Cancer Diagnosis: Date of Diagnosis: Age at Diagnosis: Treatment Received (Surgery, Radiation, Chemotherapy, Other?): Currently Under Treatment? YesNo Name of Hospital/Treatment Center: Name of Treating Oncologist: High School Information (Section C): Name of High School Attending/Attended: Status (Circle One): JRSRGRAD Graduation Date: Address: City: State: Zip Code: Status (Circle One): Current StudentAlumni Cumulative GPA (4.0 Scale): ACT Score: SAT Score: College/University Information (Section D): Name of College you will be attending in Fall 2023: Status: FRSOJRSRMASTPHD Address: City: State: Zip Code: Cumulative GPA (4.0 Scale): Major: Minor: Are you a transfer Student? YesNo What School are you transferring from? Are you a first-generation college student? YesNo Will you be an athlete in Fall 2022? YesNo What Sport: Income Information (Section E): Are you being claimed as a dependent on anyone’s tax returns? YesNo What was your adjusted Gross Family Income in 2022? Academic Honors and Awards (Section F): List any academic honors, awards, and membership activities while attending high school or college: Description: While Attending: HSCollege Start Date: End Date: Description: While Attending: HSCollege Start Date: End Date: Description: While Attending: HSCollege Start Date: End Date: Extracurricular Activities (Section F): List any academic honors, awards, and membership activities while attending high school or college: Description: While Attending: HSCollege Start Date: End Date: Description: While Attending: HSCollege Start Date: End Date: Description: While Attending: HSCollege Start Date: End Date: Statement of Accuracy: I hereby affirm that all of the above stated information provided by me is true and correct to the best of my knowledge. I hereby understand I will not submit this application without all required attachments and supporting information. Incomplete applications or applications that do not meet eligibility criteria will not be considered for this scholarship and I hereby understand that this application will become the property of LIFE Scholarship Foundation, Inc. I hereby understand that if chosen as a scholarship winner, according to the LIFE Scholarship Foundation, Inc. Scholarship policy, I must provide evidence of enrollment/registration at the post- secondary institution of my choice before scholarship funds can be awarded. I also consent that if chosen as a scholarship winner my picture may be taken and used to promote the organization’s scholarship program (may waive photo due to unusual or compelling circumstances). I hereby agree that my essay may be reprinted in part or in full for the purposes of educating, supporting and helping other college students affected by cancer. I hereby authorize (medical provider listed in section B) to provide information about my medical condition and cancer diagnosis to a representative of LIFE Scholarship Foundation, Inc. in order to support my scholarship application. I hereby understand that all financial and medical information will remain confidential. I understand Signature: Date:
