2018 Scholarship Application

HEMOPHILIA FOUNDATION OF MICHIGAN

Application for 2019 Academic Scholarship Awards
APPLICATION, SUPPORTING DOCUMENTS, AND TRANSCRIPTS ARE DUE BY MARCH 11, 2019
- Please be advised, you will need to upload your personal statement, two reference letters, and the verification of bleeding disorder letter before you are able to submit the online application.
- Please have all “official” transcripts mailed to:
Hemophilia Foundation of Michigan, Attn: Scholarship Review Committee, 1921 W. Michigan Avenue, Ypsilanti, MI 48197

Faxed, electronic, or unofficial copies will not be accepted
Full Name *

First Name Middle Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Phone Number *
Date of Birth *
E-mail *
DECLARATION OF APPLICANT

I certify that the information I have submitted is true and accurate to the best of my knowledge. Disclosing false information may jeopardize my award at any time. In the event that there is a change in any of the information presented in the application, I will promptly notify the Hemophilia Foundation of Michigan.
In the event that your are awarded a scholarship, are you willing to allow HFM to use your name in HFM publications and social media. (Your decision on this item will have no bearing on the likelihood that you will be awarded a scholarship.) *

I am willing I am NOT willing
Signature *

Clear
I. BLEEDING DISORDER INFORMATION
I have a bleeding disorder *

Yes No
-IF NO- Relationship to person with disorder: *
Type of Bleeding Disorder: *
Proof of Bleeding Disorder: Please upload a letter from a health professional verifying bleeding disorder of affected person. *
II. High School Information
High School Name
City
State
High School Graduation Date

Month Day Year
III. Post-Secondary Information

Name of post secondary school you plan to attend. (If unknown, please list in order of preference the schools to which you have applied.) Use official school names. Do not use abbreviations.

	School Name	City	State	4yr/2yr/vocational/other
1
2
3

Class level as of September 2019
Post-baccalaureate area of study (if applicable)
Major or course of study
Anticipated Date of Graduation

Month Day Year
Degree Sought
IV. EMPLOYMENT HISTORY

Describe your work experience during the past four years (e.g., food server, babysitting, lawn mowing, office work). Indicate dates of employment for each job and approximate number of hours worked each week.

	Title	Company Name	Duties	Dates: Start/Finish	Hours per week
1
2
3
4

V. Extracurricular Activities

List all school activities in which you have participated during the past four years (e.g., student government, music, sports, etc.). List all community activities in which you have participated during the past four years (e.g., Boy/Girl Scouts, hospital volunteer, Special Olympics). Note all special awards and/or honors held.

	Activity	No. of years Partic.	Special Awards/Honors	Supervisor
1
2
3
4
5
6
7

VI. RESOURCES
Have you or are you planning to complete a FAFSA form? *

Yes No

Please indicate if you are receiving or planning to apply for:

	Applied	Received
Guaranteed student loans
Work study funds
Bank loans
University scholarships
Other scholarships
Parental/Family support

VII. Personal Statement
How will receiving this scholarship help you achieve your goals and strengthen the bleeding disorders community?

Please submit a two page document (documents must be a .doc/docx or pdf)
Personal Statement *
VIII. Reference Letters
Please upload two letters of recommendation from two of the following (must be unrelated to you):

Teacher, instructor, professor, employer, community leader, healthcare provider, or other professional that knows you personally.
Letter of recommendation 1 *
Letter of recommendation 2 *
IX. Official High School Transcript
Please be advised that the process to request a transcript may take several weeks. Please allow ample time.
Please have an official transcript mailed to:

Attn: Scholarship Review Committee

1921 W. Michigan Avenue

Ypsilanti, MI 4819

*Faxed, electronic, or unofficial copies will not be accepted
X. Official College Transcripts (For those who have already attended college)
Please be advised that the process to request a transcript may take several weeks. Please allow ample time.
Please have all official transcripts mailed to:

Attn: Scholarship Review Committee

1921 W. Michigan Avenue

Ypsilanti, MI 4819

*Faxed, electronic, or unofficial copies will not be accepted
Should be Empty:

HEMOPHILIA FOUNDATION OF MICHIGAN

I. BLEEDING DISORDER INFORMATION

II. High School Information

III. Post-Secondary Information

IV. EMPLOYMENT HISTORY

V. Extracurricular Activities

VI. RESOURCES

VII. Personal Statement

VIII. Reference Letters

IX. Official High School Transcript

X. Official College Transcripts (For those who have already attended college)