BONNIE STRANGIO EDUCATIONAL SCHOLARSHIP

CF PATIENT APPLICATION FORM

Personal Information

Name                           Last                               M.I.                                         First                          

Address Street                                                     City                         State                       zip                           email

_________          ___     ____            _______________             ______________         _______________             

Date of Birth           Male    Female          Daytime Phone Number          Country of Citizenship           Social Security Number

Have you applied for a scholarship before?     Yes_____   No  ____

Did you receive one?    Yes____   No____

Family Information

Father’s name:      _________________    Mother’s name:   _______________________

Father’s profession:  _______________    Mother’s profession:  ___________________

Number of siblings:  ________                  Age of siblings:   _______________________

Education Information

Name of High School attended            City              State                 Dates attended               Overall G.P.A.             Rank in Class

Name of Undergraduate College          City                          State             Dates attended               Overall G.P.A.             Declared Major

Name of Graduate College               City              State                 Dates attended             Overall G.P.A.               Declared Major

Activities, Awards, Honors

List all school activities in which you have participated during school including sports:

Activity                                         Number of Yrs.                                Awards/Honors                      Offices Held

List all community activities in which you have participated without pay during school (i.e., civic involvement, volunteer work, etc.:

Work Experience

Indicate history of employment

Company                               Position                                  Dates                      Average hrs./week                                Salary

Essay Topic (2 parts)

a.)    Discuss the importance of compliance to CF therapies and what you practice on a daily basis to stay healthy.

b.)      Discuss your post graduation goals

(Limit essay to 2 pages double spaced)

All applicants must provide the following:

1.)      An official or unofficial high school/college transcript.

2.)      Letter from their doctor confirming diagnosis of cystic fibrosis and a list of daily medication routine.

3.)     Letter from CF Center social worker regarding financial need.

4.)     Recent photo of the applicant.

5.)     Essay.

6.)     W2 form for verification for both parents.

7.)     Application filled out completely.

*No application will be considered without ALL documents listed above.

I certify that the information presented in my application is accurate and complete. I understand and agree that any inaccurate information, misleading information, or omission will be cause for the rescission of any grant offered to me. BEF may verify any and all of my application materials.

Date:   ___________   Applicant’s signature:   __________________

CHECK WEB SITE FOR APPLICATION DEADLINE

Please mail completed form to: Jerry Cahill c/o  Boomer Esiason Foundation, Scholarship Program, 417  Fifth Avenue – 2^nd floor, New York, New York, 10016

Email questions to: jcahill@esiason.org