PART I: PERSONAL INFORMATION

PART II: BLEEDING DISORDER INFORMATION

1. Do you have a bleeding disorder? Yes No
If YES, type and severity:


2. Do others in your immediate family have a bleeding disorder? Yes No
If YES, what is their relationship to you?

3. Hematologist:
Hemophilia Treatment Center:

4. Describe how having a bleeding disorder influences your life or the life of your family (if you are not the person with the disorder).



PART III: EDUCATION INFORMATION

1. High School Graduation Date , or GED received .

2. State the post-high school education or training programs you have completed:

3. Intended college, university, trade or technical school
Name:
Address:
Program of Study:

4. Are you currently enrolled in this program? Yes No
If NO, have you applied? Yes No
     If YES, have you been accepted? Yes No (If No, go to number 5)
     Date you will begin:

5. If you have yet to be accepted into this program, when will a decision be made?

PART IV: EMPLOYMENT & FINANCIAL INFORMATION

1. List your two most recent employment experiences

2. What is the anticipated cost per semester?
Tuition:      Books:      Living Expenses:

3. What is your personal financial contribution to your education?

4. What is your parents’ financial contribution to your education?

5. How much assistance are you seeking from the Great Lakes Hemophilia Foundation?

6. Have you applied or will you be receiving a scholarship from another state or hemophilia organization?
Yes No
If yes, dollar amount:

7. Have you applied for other forms of financial aid for your education?
Yes (Go to 7a) No (Go to 7b)

7a. if yes, please complete the chart below.

Award type:	Award Amount:	Did you re-apply for this award?	Has this award been granted for ‘10-‘11?	Amt. of award approved?
University scholarships:		Yes No	Yes No Pending
Work study funds:		Yes No	Yes No Pending
Other scholarships:		Yes No	Yes No Pending
Student loans:		Yes No	Yes No Pending
Bank loans:		Yes No	Yes No Pending
Grants:		Yes No	Yes No Pending
Other:		Yes No	Yes No Pending
Total:			Total:

7b. If you have not applied for other forms of aid please thoroughly explain


8. Please indicate any other source of aid that will be used to support your education (i.e. trust fund, inheritance, etc.).


9. What are your/your family’s annual out-of-pocket expenses for the treatment and care of the individual(s) with a bleeding disorder?

Name of Individual with Bleeding Disorder	Insurance Premiums (monthly)	Medication co-pays related to bleeding disorder (monthly)	Other (Medical Appt., hospitalizations, etc.)

10. Please check the statement that applies, and fill in the information requested. This information will help us estimate your/your family’s level of financial need.

I am being claimed on my parents’ tax returns.
The annual family income is ; family size is .

I am supporting myself.
My annual income is .

I am supporting, or helping to support, my family.
The annual family income is ; family size is .

11. Please identify any extenuating financial circumstances that may further explain your/your family’s financial situation.


PART V: DECLARATION OF APPLICANT

By clicking the box, I certify that I have read and agree to the following statement.

I certify that the information I have submitted is true and accurate to the best of my knowledge. The essay and application was completed by me, the applicant. In the event that there is a change in any of the information presented in the application, I will promptly notify the Great Lakes Hemophilia Foundation.

In the event that I am awarded program assistance, I am/ am not willing (check one) to allow the Great Lakes Hemophilia Foundation to use my name and photo in publicity or promotion of the program. (Your answer to this question will have no impact on eligibility or award.)

Signature:    Date:

I certify that the above typed name is valid as an electronic signature.
Signature of Parent /Guardian if under 18 years of age.

Be sure to print this page for your records before submitting.