Scholarship Application

THE APPLESEED PROJECT

Scholarship Application
Full Name*

First NameLast Name
Contact Number*
Please enter a valid phone number.
Email Address*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
What is your gender*
Please enter your date of birth*

MonthDayYear
Date
Have you received a Scholarship in the past?*

YesNo
If Yes, what date?:blanks (MM/DD/YYYY).
Did you receive a free registration, shared room, or both?blank
What type of active cancer(s) do you have?*
Please enter the date of when you were first diagnosed*

MonthDayYear
Date
Would you like to attend the conference in person or via live stream*

In PersonLive Stream
For the in person scholarship request, we offer two options: Option 1: Two free nights in a shared hotel room with another scholarship recipient (extra nights are provided at your own expense) or Option 2: Full access to the conference. Please indicate your preference

Option 1: 2 Free nights in a shared roomOption 2: Full access to the conference
If you selected option 2: will you be getting your own hotel room or would you like us to pair you up with another scholarship recipient to share hotel costs?

I will be getting my own roomPlease pair me with someone
Describe your cancer journey, including your diagnosis, treatment, and current status*
Please explain your financial burden*
In what ways do you plan to use the information or experiences gained from the conference to support your own health*
Describe any involvement you have had in cancer support groups, advocacy, or other related activities.*
I understand that scholarships are only available to those currently living with active cancer. Any family/friends/support attending must purchase their own ticket*

Yes, I understand
Should be Empty:

THE APPLESEED PROJECT