2014 Scholarship Application*
I. Personal Information
1. Name of Applicant_________________________________________
2. Address_________________________________________________
_______________________________________________
3. Phone___________________________________________________
4. E-mail address_____________________________________________
5. Date of Birth_______________________________________________
6. Diagnosis of Bleeding Disorder
Hemophilia A______ Hemophilia B______
von Willebrands _____ Type (I, 2, 2A, 2B, 2M, 2N, or 3)____________
Other_________________(Factor I, Factor II, Factor V, Factor VII, Factor X,
Factor XI, or Factor XIII, Glanzman’s, etc.).
II. Education/ Employment
7. Institution of higher education which you plan to attend or are attending
________________________________________________________
8. Current admission status at above institution
________________________________________________________
9. Field of major interest and degree or certificate expected (If you are applying for the
Steve Keale Memorial Scholarship, please indicate what area of the visual or
performing arts in which you are interested)
________________________________________________________
10. List all school or community activities you have taken part in. Also, please highlight
any awards, honors and offices held.
___________________________________________________________
___________________________________________________________
11. Employment Goals:
________________________________________________________
III. Employment History:
List your most recent employment experiences:
Employer_________________________________________________
Dates_____________ Full or part time_________________________
Description of Duties_______________________________________
________________________________________________________
Employer__________________________________________________
Dates______________Full or part time__________________________
Description of Duties_________________________________________
_________________________________________________________
IV.
Will you be attending college full-time_______or part-time___________
V. What other sources are you contacting to help finance your schooling?
Check those contacted and the date.
I.
Government Grants
_________
____________
__________
Government Loans
_________
_____________
__________
Work Study
_________
____________
___________
School Financial
Aid Office
_________
____________
___________
Employer
_________
____________
___________
Parents
_________
____________
___________
Other
_________
____________
___________
Scholastic Record
Please request that your transcripts be forwarded to the HFNC office as
soon as possible (unofficial transcripts are acceptable). They must be postmarked
no later than July 31, 2014.
VII.
References
List the names of two references (other than family members) below. Please
contact them and request that they forward a letter of recommendation to the
HFNC office prior to the deadline.
________________________________________________________________
________________________________________________________________
VIII.
Essay question
On a separate sheet(s) of paper please either type or legibly print an essay that
describes your academic, personal, and professional goals and how you expect your
education to help you achieve them. [If this is your first application for a HFNC
scholarship, please limit your essay to 500 words. If you are a repeat applicant, in
addition to the above information, please share how your college experiences are
assisting you in meeting your professional goals and limit you essay to 1000 words.]
*PLEASE NOTE THE FOLLOWING REQUIREMENTS TO BE ELIGIBLE FOR A HFNC SCHOLARSHIP:

All applicants must be enrolled in a college/university or trade school

All applicants must have been born or currently reside in the following California Counties: Alameda,
Contra Costa, Del Norte, Fresno, Humboldt, Kings, Madera, Marin, Mariposa, Mendocino, Merced,
Monterey Napa, San Benito, San Francisco, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma,
Stanislaus, Tulare
Please return completed applications, essays, letters of recommendation, and all transcripts to the HFNC
office postmarked no later than July 31, 2014.
HFNC Scholarships, 6400 Hollis Street, Suite 6, Emeryville, CA 94608