New Customer Registration Form

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

E-mail*

example@example.com

Birth Date*

Date

I am applying for the following scholarship(s). Applicant may apply for both scholarships, if eligible.*

T.D. HughesGina Stack Memorial Scholarship

High School (if recent graduate), or institution currently attending*

College/University/Technical School/Graduate School Class you will be entering (please check one*

Name of College/University/Technical School/Graduate School for which scholarship is intended*

Are you taking classes on the main campus or a satellite campus? *

Year of anticipated graduation from College/University/Technical School/Graduate School *

Grade Point Average (GPA) on a 4.0 scale. *

Please attached proof of GPA. Your most recent unofficial or official transcript is required.*

What is your major/degree? If major is undeclared, state reason.*

List other financial assistance you will receive per semester or quarter. Please list all scholarships and student loans. Include the amount of each.*

List any scholarships and the year received that you were previously awarded from TSBDF. If none, state NONE.*

Do you have a bleeding diagnosis or are you an immediate family member of a person with a bleeding disorder?*

SelfImmediate Family Member

Relationship to person with bleeding disorder. Please include family member's name. Type N/A if self*

Bleeding Disorder Diagnosis*

Name of current hematologist or Hemophilia Treatment Center *

List your academic honors, awards, and membership activities Include the year(s) you received the award/honor and year(s) of membership activities. For the 2nd or subsequent year of a TSBDF scholarship application only list those for the past year.*

List your community service activities, hobbies, outside interests, and extracurricular activities, including those associated with the bleeding disorders community. For the 2nd or subsequent year of a TSBDF scholarship application only list those for the past year. *

List the name of the person who will be sending in a recommendation letter on your behalf (required for first-time applicants only). Recommendation letters from relatives are not acceptable.*

Do you have financial need or extreme challenges? If so, please explain in general terms. Put n/a if not.*

List your FAFSA score (Free application for Federal Student Aid) if available. Put n/a if not available.*

List your goals, aspirations, and choice of major: NOTE: Applicants of the Gina Stack Memorial Scholarship must be pursuing a full-time degree program with a focus on the healthcare or medical profession.*

ESSAY: Upload your document below as a typed, 12-point font, double-spaced essay with a 600-word maximum.

First Time Applicants

Your essay should include the following:
• Your career objective
• Why you have chosen this field
• Your personal characteristics that will contribute to your success in attaining your education and career goals
• How your bleeding disorder (or your family member’s bleeding disorder) influenced your career objective.

Returning Applicants for a second or subsequent year scholarship

Your essay should include the following:
• A brief review summarizing your progress for the recent academic year along with your future plans.
• What advice would you be willing to share with younger students preparing to enter college or technical school?

Upload Your Essay Here*

Please upload proof of enrollment of letter of acceptance to college or technical school.*

PERSONAL/PROFESSIONAL REFERENCE FORM

Please download the form or print and mail it to the person who knows you well enough to recommend you for this scholarship. References from family members are not acceptable.
All reference letters must be emailed to Hemophilia@TSBDF.com by June 1, 2024 or mailed to: TSBDF, 635 W 7th Street, Ste. 407, Cincinnati, OH 45203.

Mailed reference letters must by post-marked by June 1, 2025.

DOCUMENTATION OF A BLEEDING DISORDER BY HEMATOLOGIST OR TREATMENT CENTER PHYSICIAN/NURSE

Please print this form, complete the top portion of this form and then give it to the treating hematologist or their nurse who can document your diagnosis of a bleeding disorder. If it is your immediate family member who has a bleeding disorder diagnosis, documentation of that family member’s diagnosis and their relationship to you is required.

This is not required for returning applicants.

Documentation must be post marked or emailed by June 1, 2025

ACKNOWLEDGEMENT
• I hereby affirm that all the above stated information provided by me is true and correct to the best of my knowledge.
• I hereby understand that if chosen as a scholarship winner, I must provide evidence of enrollment/registration at an accredited, post-secondary institution before my scholarship funds can be awarded.
• I hereby affirm that if I withdraw from school within my institution’s window to receive a tuition refund, I will return the scholarship to TSBDF.
• All applications and communications must come directly from the applicant. Applications will not be accepted from anyone other than the applicant.
• I hereby acknowledge that the medical information you are providing to T.S.B.D.F. will be shared with the scholarship selection committee as part of your application.

Signature*

2025 TSBDF Scholarship Application