scholarship  Application

Applicant Information

Name:

Date of birth:

SSN:

Phone:

Current address:

City:

State:

ZIP Code:

Male:                Female:

Single:        Married:        Divorced:

 

Fathers Name:

Occupation:

D.O.B:

Mothers Name:

Occupation:

D.O.B:

Names of Brothers & Sisters:

Age:

 

 

 

 

 

 

 

 

 

 

Are you a citizen of the U.S.:   Y or N

 

 

education

Name of institution:

Address:

Yrs:                  Graduate:  Y  or N

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever been convicted of a crime:   Y  or N

If yes please explain:

 

 

List Colleges/Universities, Technical Schools/Institutes of Advanced Learning,  to which you have applied and status in order of preference:

 

 

Intended Field of Study:

 

List all honors and achievements:

 

List all high school extracurricular activities or elected offices:

 

List any high school sports you participated in:

 

List any community, civic, volunteer or charitable organization for which you have worked:

 

 

 

References  

Name

Address

Phone

 

 

 

 

 

 

 

 

On a separate sheet, please describe how cancer has affected your life:  (250 word max)

 

 

 

On a separate sheet, please discuss your career goals and how this scholarship might assist you in achieving these goals:  (250 word max.)

 

 

 

Have you received or are you under consideration for any other scholarships?  (if yes, please state scholarship?  (Include criteria, source and amount)

 

 

 

Please enclose an official high school transcript and two letters of

Of recommendation.

 

 

 

Signatures

I certify that all of the above statements are true to the best of my knowledge.

Name:

Date:

Signature:

Date:
       

Note:  Providing false or misleading information will result in disqualification from consideration

 

Eligibility Requirements:

1.        Applicant must be a senior in high school in good academic standing and can not have previously attended a college or university

2.        Applicant must enroll and remain as a full time student in an institute of higher learning in the United States beginning in the fall of 2006.

3.        Applicant must have/had cancer  him/herself, or have an immediate family member who has cancer.

4.        Application Deadline:  June 17th, 2006

 

Return to:

The Dean Michael Clarizio Cancer Foundation

10 Connel Drive

West Orange, NJ  07052

 

Note:  Do not enclose original documents.  Copies of honors, awards, etc. are acceptable.

The scholarship committee will schedule interviews with applicants designated as finalists.

The scholarship committee reserves the right not to award the Dean Michael Clarizio Cancer Foundation Scholarship if, in its view, the present competition does not meet the established standards.

 

You may visit our website:  deanmichaelclariziocancerfoundation.org