Natalie Marc Surpris Scholarship Application 2022

All applications MUST be submitted by October 1, 2022

Name *

Date *

Date

Gender *

Race *

Home Address *

City *

State *

Zip *

Primary Telephone *

Secondary Telephone

Email *

example@example.com

Date of Birth *

MM/DD.YYYY

What school do you currently attend?

School Name *

School City *

School State *

School Zip *

What school do you plan to attend in the Fall of 2022? *

I will be attending as a: *

Freshman Sophmore Junior Senior

Grade Point Average (GPA) *

4.0 Scale

Name of parent(s) or legal guardian(s) with cancer diagnosis *

Parent's Primary Telephone *

Cancer Diagnosis *

What form of treatment is or was received? *

How long has your parent(s) been battling or battled cancer? *

Personal Essay: Please answer the following questions:

1. What type of cancer diagnosis does your parent/legal guardian have?

2. How long has your parent/legal guardian been battling cancer?

3. How has this impacted your life?

4. Knowing how cancer has a big impact on lives, how did you remain a model student?

5. How will you utilize the scholarship fund to help with your academic journey?

6. Choose one of the following:

If you could change any part of the cancer journey for your parent/legal guardian, what part would it be?
If you can change any part of the cancer journey for yourself, what part would it be?

The essay should be written in a minimum of 1000 words.

Please upload Personal Essay here *

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List of supporting documents:

Proof parent or legal guardian is diagnosed with cancer.
Copy of birth certificate or court document showing proof of Legal Guardian
Death Certificate
Proof of cancer treatment. All forms must be signed by the treating physician.

Examples below:

History of diagnosis and treatment with start and end date (if applicable).

Summary/Soap note from last appointment with an oncologist or treating physician, with history or present diagnosis/treatment with start and end date (if applicable).
Proof you are a High school senior or College undergrad student(Verification of Enrollment)
Unofficial Transcript to prove at least 3.0 GPA

Please upload supporting documents here *

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Statement of Accuracy

I hereby affirm that all the above stated information provided by me is true and correct to the best of my knowledge. I also consent that my picture may be taken and used for any purpose deemed necessary to promote the Natalie Marc Surpris Scholarship Fund. I hereby understand that if chosen as a scholarship recipient, according to the Natalie Marc Surpris Scholarship Fund policy, I must provide evidence of enrollment/registration at the college of my choice before scholarship funds can be awarded.

Applicant Signature *

Clear

Date *

Date

Deadline: The application form and all other required documentation must

be submitted by October 1, 2022. Any applications received after the

deadline will NOT be considered. Please carefully review the Natalie

Marc Surpris Scholarship Fund Policy/Guidelines for a complete list of

documents required for eligibility. Please submit questions or concerns via email or phone to Gensen M. Surpris at:

info@westandtogetherinc.org or 954-667-9336