Mary E Smith Foundation Scholarship Application

Mary E. Smith (M.O.M) Foundation, Inc./ Memories of Mary Scholarship Application

Application Deadline - March 1st
ELIGIBILITY: All applicants must be U.S. residents. All applicants must submit a transcript to complete the application prior to the submission deadline. All applicants must complete an essay at time of completing this online application. All applicants must provide the name, title & email address of their formal reference; which must be a guidance Counselor, Principal, Professor/Teacher or President/Dean of College at the time of submission. In addition, all applicant's have the sole responsibility of providing the Reference & Rating link embedded here via copy & paste to their referring person, as well as following up on thier submission of reference by the March 1st deadline.

A. Excellence in Academics and Community Service Award

Must be a brain tumor patient/survivor or closely related to someone diagnosed with a brain tumor. Relationships are limited to spouse, biological children, biological parents, biological siblings. Must be entering or currently enrolled in an advanced educational program at a college, university, vocational school or other setting within the fifty United States or District of Columbia. Must have at least a GPA of 3.0/4.0 or a 4.0/5.0. l Rank in top half of class and have at least an SAT score of 1000 or an ACT of 21. Demonstrate strong leadership and service in their community.

B. Excellence in Science and Medicine Award

Must be entering or currently enrolled in an advanced educational program within the health sciences (including biology, chemistry, nursing, etc.) with the intent to enter the field of oncology or neurology (including neuroscience, neurosurgery, and neuropathology) at a college or four-year university within the fifty United States or District of Columbia. Must have a GPA of 3.0/4.0 or 4.0/5.0. l Must have three (3) years of science courses with a minimum grade letter of B in each course. Rank in the top half of class and have at least an SAT score of 1000 or an ACT of 21.

C. The Karen Lewis CTU Excellence in Science Award

Created in honor of Chicago Teachers Union (CTU) President Karen Lewis. Must be a current student or graduate of a Chicago Public School (CPS). Must be entering or currently enrolled in an advanced educational program within the health sciences (including biology, chemistry, nursing, etc.); pursuing a technical certification, associate or bachelor level degree; with an emphasis in science and/or screening and research in the areas of oncology or neurology (including neuroscience, neurosurgery, and neuropathology) at a college or four year university within the fifty United States or District of Columbia. Must have a GPA of 3.0/4.0 or 4.0/5.0. Must have three (3) years of science courses with a minimum grade letter of B in each course. Rank in the top half of class and have at least an SAT score of 1000 or an ACT of 21.
Please select the scholarships above in which you are eligible to apply for. *

Excellence in Academics & Community Service Award Excellence in Science & Medicine Award The Karen Lewis CTU Excellence in Science Award A and C B and C
If applying for Scholarship A; select applicant relationship to the patient/survivor and complete the diagnosis information.

I am the patient I am the child of the patient I am the Sibling of patient
Patient Tumor Type
Date of Patient Diagnosis
Diagnosing Facility Name
Facility Location

Street Address:

Street Address Line 2

City State / Province

Postal / Zip Code
I have read and understand the eligibility requirements. *

Yes, I have
If selected, you will be asked for documentation to support the data you provide. Likewise, all correspondence and award agreements will be generated from the personal information submitted below. So, please use proper spelling, capitalization and punctuation.
I. Personal Data:

Tell us about yourself
Full Name *

First Name Last Name
Birthdate: *

Month Day Year
Home/Mobile No. : *

Area Code Phone Number
E-mail : *
Where the confirmation will be send to
Home Address : *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Optional Informations : Information regarding gender, ethnic origin and race are optional. The information is requested for post-scholarship report generation only and in no way affects your selection for college scholarship awards. However, providing this information may increase your opportunities for scholarships where donors have asked that priority consideration be given to students meeting certain demographic criteria (such as minority status, parent's place of employment, area of study, etc.)
Gender:

Male Female
Are you a US citizen?

Yes No
Ethnic Origin:

Hispanic Non-Hispanic Not Indicated
Race? (Choose one or more):

White Black or African American Asian American Indian or Alaskan Native Hawaiian or Other Pacific Islander Non-Resident Alien
II. High School & College/University Information:
Name of High School *
School Location : *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Current GPA: *
Cumulative GPA: *
Class Rank:
Year of High School Graduation or GED: *
High School activities such as offices held or other honors, community activities, volunteer work with name of organization & amount of time spent in days/months/years of service:: *
Name of College/University: *
City & State of College/University: *
If currently enrolled cumulative GPA: *
Major or anticipated Area of Study *
College/University activities such as offices held or other honors, community activities, volunteer work with name of organization & amount of time spent in days/months/years of service:
III. ACT and/or SAT Information:
ACT composite (overall) score?
SAT score:
All scholarship applicants reporting an ACT/SAT score will be asked to provide official verification.
IV. For Medical School Applicants :
Current GPA:
School activities, honors, offices held, etc.:
V. Essay
Your essay should be 300-1500 words.

May E. Smith (M.O.M.) Foundation, Inc./Memories of Mary has taken positive stands on important issues affecting the community and takes pride in working for the betterment of all people. Select a current issue important to you and discuss how your education will allow you to make an impact on that issue.
Essay:

0/500
VI. Reference and Rating Form

The Reference & Rating form MUST be completed by a Guidance Counselor, Principal, Professor/Teacher or President/Dean of College utilizing the link embedded here that you MUST provide to them via a copy & paste of the form link https://form.jotform.com/220006715930042. The reference should match the information you provide in this section.
Full Name of Reference *

First Name Last Name
Title of Reference: *
Name of Reference Organization/School: *
Email Address of Reference: *
VII. Applicant's Attestation & E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please retain for your records as verification of your application.
I Agree

YES, I am sending a copy of my school transcript to Mary E. Smith Foundation, Inc. 2035 S. State St #16-703 Chicago, IL. 60616. Fax 708-342-0800 Email information@maryesmithfoundation.org. Furthermore, If chosen as a recipient, I will provide an official copy to the charity & participate in recipient acknowledgement activities (annual brain tumor walk & scholarship event).
Signature

Clear
Should be Empty:

Mary E. Smith (M.O.M) Foundation, Inc./ Memories of Mary Scholarship Application

I. Personal Data:

II. High School & College/University Information:

III. ACT and/or SAT Information:

IV. For Medical School Applicants :

V. Essay

VI. Reference and Rating Form

VII. Applicant's Attestation & E-Signature