Terry Lamb Enrichment Scholarship

Virginia Bleeding Disorders Foundation (VABDF) Terry Lamb Enrichment Scholarship

Go here to read the Terry Lamb Enrichment Scholarship Application Procedure & Guidelines.

If you have questions about this scholarship please reach out to Heather Conner at 804-740-8643 or heather@vahemophilia.org

Please confirm that you have read the Terry Lamb Enrichment Scholarship Application Procedure & Guidelines

Name of applicant

First NameLast Name

Date of birth

Date

Is the applicant under 18 years of age?

Name of Parent or Guardian if applicant is under 18 years of age

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell Phone Number

If applicant is under 18, Please enter the parent/caregiver's phone number.Format: (000) 000-0000.

Email

If applicant is under 18, Please enter the parent/caregiver's email address.

How did you hear about VABDF/VHF's Terry Lamb Enrichment Scholarship?

Please describe the program and/or activity that you are applying for?

Start date of program and/or activity

Date

Cost of program and/or activity

Payment deadline of program and/or activity

Date

Have you or a family/household member ever received funding or a scholarship from VABDF/VHF?

If yes, what was the funding for and how much was it for?

Do you have an inherited bleeding disorder?

What type of inherited bleeding disorder do you have?

Where do you receive treatment for your bleeding disorder?

If you answered no, please list which family/household member(s) does and their relationship to you.

Does the affected family member live in your household?

Other

What type of inherited bleeding disorder does your family/household member have?

Where does the family/household member with an inherited bleeding disorder receive treatment for their bleeding disorder?

Would you be willing and/or able to still participate in the meeting, program and/or activity if a partial scholarship is offered/available?

If you answered no or maybe, please explain

How has an inherited bleeding disorder affected you and/or your family’s lives? Your response should be a minimum of 100 words.

Explain what you hope to gain by participating in this meeting, program, and/or activity. Your response should be a minimum of 100 words.

Describe your previous participation with the chapter and how you plan to contribute to VABDF/VHF and support persons with inherited bleeding disorders. Your response should be a minimum of 100 words.

Optional: Financial Consideration - Please describe any financial circumstances, educational barriers, medical challenges, or other factors you would like the scholarship committee to consider when reviewing your application.

Declaration of Application

I certify that the information I have submitted is true and accurate to the best of my knowledge. I authorize the release of information to VABDF/VHF to verify all statements made in this application. Disclosing false information may jeopardize my award at any time. I also give permission to use my name/and or photo in VABDF's/VHF’s website, News, or any other press release that VHF deems appropriate.

I have read, understand, and agree.

Signature applicant

Signature of parent/guardian if applicant is under the age of 18

Today's date

Date