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Get Transplant Recipient Scholarships In Georgia Form

Scholarships are in the amount of 1 000 and are renewable for a period up to four years depending on educational program requirements and continuing to meet grade requirements. The Thomas F. Smith Scholarship is awarded to a transplant recipient in honor of Thomas F. Smith. Mr. Smith a kidney recipient founded the Georgia Transplant Foundation in 1992. The Dunkerley Family Scholarship is awarded to a dependent of a recipient in honor of the Dunkerley family. Scholarship Program Realizing that transplantation poses financial hardships on the entire family the Georgia Transplant Foundation annual awards seven academic scholarships to selected students who are transplant recipients dependents of a transplant recipient living donors or the sibling of a transplant recipient under the age of 22. The scholarships are awarded to students who are presently enrolled in an accredited institution or beginning such a program. Scholarships will be awarded for tuition fees and books and may include room and board costs. It is preferred that all parts of the application be mailed together. This includes transcripts and letters of recommendation. Please submit entire Application Packet to Georgia Transplant Foundation 500 Sugar Mill Road Suite 170-A Atlanta GA 30350 Attention Scholarship Program Sample Student Biography Mr. John Smith 1234 State Road Anytown USA 12345 404-333-1234 Anytown High School or University or Technical School Community Service Humane Society September 2003-current Washed animals and assisted with adoption process American Cancer Society June 2004-August 2006 Completed general office work and assisted at fundraisers Special Awards Honors and Scholarships Student Award of Distinction 2006 Senior Class Leadership Award 2006 National Honor Society 2003-2006 Scholarship of Merit State University 2005 Clubs School Activities/Athletics Key Club 2003-2006 President 2006 Outdoor Club 2003-2006 Drama Club 2002-2006 Varsity Soccer 2002-2006 JV Basketball 2002-2003 Captain 2003 Work Experience Brian s Hot Dogs June 2006-August 2006 20 hours/week Shop-A-Rama June 2005-August 2005 Skate n Fun June 2004-August 2004 Please make sure your Scholarship Packet is complete by checking the following items Scholarship Application Form Transcripts High School transcript / College Technical school transcript High School exit exams SAT/ACT/Admission exam scores Acceptance letter or most recent registration forms Personal Statement 3 Sealed Letters of Recommendation from Income Tax Forms- first 2 pages showing adjusted gross income Signatures Applicant Parent Incomplete applications will not be considered or returned. ACADEMIC SCHOLARSHIP APPLICATION Providing this information will not adversely affect any consideration you may receive for GTF services CLIENT INFORMATION First Name Middle Name Last Name Mailing Address Apartment/Unit City State Home Phone Male / Date of Birth Zip Code County Cell Phone Female E-mail Marital Status Spouse s Name if applicable Age Social Security Number Total of People Living in Household Children in Household Adults in Household Date of Transplant if applicable Organ Transplant Center DEMOGRAPHIC INFORMATION Race optional - please check Hispanic African American Level of Education optional -please check GED Technical Certificate/Diploma Associates Degree Work Status please check Native American Attended High School of years Currently Enrolled in College Other High School Graduate Attended College of years Masters Degree Full-Time Employment with benefits Part-Time Employment White Non-Hispanic Asian-Pacific Islander Bachelors Degree Current Source of Income please check all that apply Black MD/PhD Parents Income Other Working Spouse Retirement Pension Supplemental Security Income SSI Currently Employed Employer Name Medically Disabled Retired Unemployed Date Insurance please circle BCBS United Healthcare Humana Kaiser Aetna Other Spouse s Insurance Medicare COBRA Check all that apply to you Medicaid Recipient Spend-down Medicaid Candidate Trends In Transplant TNT Conference Attendee Mentor with The Mentor Project How did you hear about GTF services Revised January 2012 Fundraising Workshop Attendee GTF Volunteer/ Board Member/ Committee Member GTF Website/ IMPRINT Magazine/ Brochure GTF Volunteer Name JumpStart Client GTF Staff Name 2013 Scholarship Application Form PERSONAL DATA Name Last First Middle Name Called QUALIFYING DATA Georgia Resident Transplant Recipient Dependent of a Transplant Recipient Sibling of a Transplant Recipient 22yo Parent of a Transplant Recipient Name of Recipient Date of Transplant Type of Transplant COLLEGE / PROGRAM INFORMATION Name of institution you plan to attend Reason for selecting this institution What degree or certificate are you pursuing. Freshman Sophomore Junior Senior other Have you been accepted into this school or program Yes No Date Accepted What is your expected starting date Expected completion date List all high schools technical schools and colleges/universities which you have attended School GPA City State Name of your current school What is your present class standing or GPA list scores here do not say see attached Writing Language Arts Math Social Studies SAT Score Science Reading ANTICIPATED COLLEGE EXPENSES Projected cost per year Tuition/fees Books Campus Housing Meal Plan TOTAL Have you applied for or received a Pell Grant or other governmental grants Yes No Amount Will you have tuition reduction or grants from the institution you are attending Please list any other scholarships you have received the amount and whether it is a one time or renewable Amount Duration Do you currently owe a repayment on a student loan No Yes Approximate amount FINANCIAL STATEMENT Applicants are encouraged to review any tax implications of this program with their professional tax advisor. John Smith 1234 State Road Anytown USA 12345 404-333-1234 Anytown High School or University or Technical School Community Service Humane Society September 2003-current Washed animals and assisted with adoption process American Cancer Society June 2004-August 2006 Completed general office work and assisted at fundraisers Special Awards Honors and Scholarships Student Award of Distinction 2006 Senior Class Leadership Award 2006 National Honor Society 2003-2006 Scholarship of Merit State University 2005 Clubs School Activities/Athletics Key Club 2003-2006 President 2006 Outdoor Club 2003-2006 Drama Club 2002-2006 Varsity Soccer 2002-2006 JV Basketball 2002-2003 Captain 2003 Work Experience Brian s Hot Dogs June 2006-August 2006 20 hours/week Shop-A-Rama June 2005-August 2005 Skate n Fun June 2004-August 2004 Please make sure your Scholarship Packet is complete by checking the following items Scholarship Application Form Transcripts High School transcript / College Technical school transcript High School exit exams SAT/ACT/Admission exam scores Acceptance letter or most recent registration forms Personal Statement 3 Sealed Letters of Recommendation from Income Tax Forms- first 2 pages showing adjusted gross income Signatures Applicant Parent Incomplete applications will not be considered or returned. ACADEMIC SCHOLARSHIP APPLICATION Providing this information will not adversely affect any consideration you may receive for GTF services CLIENT INFORMATION First Name Middle Name Last Name Mailing Address Apartment/Unit City State Home Phone Male / Date of Birth Zip Code County Cell Phone Female E-mail Marital Status Spouse s Name if applicable Age Social Security Number Total of People Living in Household Children in Household Adults in Household Date of Transplant if applicable Organ Transplant Center DEMOGRAPHIC INFORMATION Race optional - please check Hispanic African American Level of Education optional -please check GED Technical Certificate/Diploma Associates Degree Work Status please check Native American Attended High School of years Currently Enrolled in College Other High School Graduate Attended College of years Masters Degree Full-Time Employment with benefits Part-Time Employment White Non-Hispanic Asian-Pacific Islander Bachelors Degree Current Source of Income please check all that apply Black MD/PhD Parents Income Other Working Spouse Retirement Pension Supplemental Security Income SSI Currently Employed Employer Name Medically Disabled Retired Unemployed Date Insurance please circle BCBS United Healthcare Humana Kaiser Aetna Other Spouse s Insurance Medicare COBRA Check all that apply to you Medicaid Recipient Spend-down Medicaid Candidate Trends In Transplant TNT Conference Attendee Mentor with The Mentor Project How did you hear about GTF services Revised January 2012 Fundraising Workshop Attendee GTF Volunteer/ Board Member/ Committee Member GTF Website/ IMPRINT Magazine/ Brochure GTF Volunteer Name JumpStart Client GTF Staff Name 2013 Scholarship Application Form PERSONAL DATA Name Last First Middle Name Called QUALIFYING DATA Georgia Resident Transplant Recipient Dependent of a Transplant Recipient Sibling of a Transplant Recipient 22yo Parent of a Transplant Recipient Name of Recipient Date of Transplant Type of Transplant COLLEGE / PROGRAM INFORMATION Name of institution you plan to attend Reason for selecting this institution What degree or certificate are you pursuing. Freshman Sophomore Junior Senior other Have you been accepted into this school or program Yes No Date Accepted What is your expected starting date Expected completion date List all high schools technical schools and colleges/universities which you have attended School GPA City State Name of your current school What is your present class standing or GPA list scores here do not say see attached Writing Language Arts Math Social Studies SAT Score Science Reading ANTICIPATED COLLEGE EXPENSES Projected cost per year Tuition/fees Books Campus Housing Meal Plan TOTAL Have you applied for or received a Pell Grant or other governmental grants Yes No Amount Will you have tuition reduction or grants from the institution you are attending Please list any other scholarships you have received the amount and whether it is a one time or renewable Amount Duration Do you currently owe a repayment on a student loan No Yes Approximate amount FINANCIAL STATEMENT Applicants are encouraged to review any tax implications of this program with their professional tax advisor. Current year income tax return pages 1-2 showing adjusted gross income for parents and applicant must be attached. Estimated total ANNUAL FAMILY income Number of working adults Number of children in applicant s family Does the annual family income include Spouse s income Applicant s income Will income continue during school Yes No Please list others in your household currently in school Name Relationship School Elementary High School College Expected Date of Completion Tuition SIGNATURES I declare that the information reported is true correct and complete. Long-term goals. Essay specifications typed double-spaced no more than 3 pages. LETTERS OF RECOMMENDATION Include three sealed letters of recommendation. Recommendations should be brief. No letters from relatives or classmates will be accepted. Contact information for reference should be included. INCOME TAX FORMS Copy of most recent Federal Income Tax Return pages 1 and 2 showing adjusted gross income of all members of your household. It is preferred that all parts of the application be mailed together. This includes transcripts and letters of recommendation. Please submit entire Application Packet to Georgia Transplant Foundation 500 Sugar Mill Road Suite 170-A Atlanta GA 30350 Attention Scholarship Program Sample Student Biography Mr. John Smith 1234 State Road Anytown USA 12345 404-333-1234 Anytown High School or University or Technical School Community Service Humane Society September 2003-current Washed animals and assisted with adoption process American Cancer Society June 2004-August 2006 Completed general office work and assisted at fundraisers Special Awards Honors and Scholarships Student Award of Distinction 2006 Senior Class Leadership Award 2006 National Honor Society 2003-2006 Scholarship of Merit State University 2005 Clubs School Activities/Athletics Key Club 2003-2006 President 2006 Outdoor Club 2003-2006 Drama Club 2002-2006 Varsity Soccer 2002-2006 JV Basketball 2002-2003 Captain 2003 Work Experience Brian s Hot Dogs June 2006-August 2006 20 hours/week Shop-A-Rama June 2005-August 2005 Skate n Fun June 2004-August 2004 Please make sure your Scholarship Packet is complete by checking the following items Scholarship Application Form Transcripts High School transcript / College Technical school transcript High School exit exams SAT/ACT/Admission exam scores Acceptance letter or most recent registration forms Personal Statement 3 Sealed Letters of Recommendation from Income Tax Forms- first 2 pages showing adjusted gross income Signatures Applicant Parent Incomplete applications will not be considered or returned. ACADEMIC SCHOLARSHIP APPLICATION Providing this information will not adversely affect any consideration you may receive for GTF services CLIENT INFORMATION First Name Middle Name Last Name Mailing Address Apartment/Unit City State Home Phone Male / Date of Birth Zip Code County Cell Phone Female E-mail Marital Status Spouse s Name if applicable Age Social Security Number Total of People Living in Household Children in Household Adults in Household Date of Transplant if applicable Organ Transplant Center DEMOGRAPHIC INFORMATION Race optional - please check Hispanic African American Level of Education optional -please check GED Technical Certificate/Diploma Associates Degree Work Status please check Native American Attended High School of years Currently Enrolled in College Other High School Graduate Attended College of years Masters Degree Full-Time Employment with benefits Part-Time Employment White Non-Hispanic Asian-Pacific Islander Bachelors Degree Current Source of Income please check all that apply Black MD/PhD Parents Income Other Working Spouse Retirement Pension Supplemental Security Income SSI Currently Employed Employer Name Medically Disabled Retired Unemployed Date Insurance please circle BCBS United Healthcare Humana Kaiser Aetna Other Spouse s Insurance Medicare COBRA Check all that apply to you Medicaid Recipient Spend-down Medicaid Candidate Trends In Transplant TNT Conference Attendee Mentor with The Mentor Project How did you hear about GTF services Revised January 2012 Fundraising Workshop Attendee GTF Volunteer/ Board Member/ Committee Member GTF Website/ IMPRINT Magazine/ Brochure GTF Volunteer Name JumpStart Client GTF Staff Name 2013 Scholarship Application Form PERSONAL DATA Name Last First Middle Name Called QUALIFYING DATA Georgia Resident Transplant Recipient Dependent of a Transplant Recipient Sibling of a Transplant Recipient 22yo Parent of a Transplant Recipient Name of Recipient Date of Transplant Type of Transplant COLLEGE / PROGRAM INFORMATION Name of institution you plan to attend Reason for selecting this institution What degree or certificate are you pursuing..

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