Sabrina House Children’s Charity
P.O. Box 1174
Pickens, SC 29671
864-417-5964
Amanda House Martin Scholarship
TO BE ELIGIBLE, AN APPLICANT:
1. Must be a hematology or oncology patient of the BI-LO Charities
Children’s Cancer Center of Greenville, SC with a chronic or recurrent
illness requiring treatment for a minimum of six months or more.
2. Must be a senior in high school or an undergraduate student already
enrolled in college and must be planning to attend college in the Fall of
2012.
3. Submit an essay on the following topic: “Why I decided to attend
college and how I will use my education to help others.” Please
include any factors that influenced your decision to pursue a college
degree. You may discuss people who affected your decision making
process.
The essay should be in size 12 font, and no longer than four pages doublespaced.
We will award two individual scholarships, each worth $500. The scholarships
will be awarded for students attending a 4-year college or university or a 2-year
community or technical college. All monies will be issued directly to the college
or university. This is a one time scholarship that is not automatically
renewable. Applicants must re-apply each year in order to be considered
for additional scholarship funds.
There are no special eligibility requirements for the scholarship. All students may
apply regardless of their race, religion, nationality or financial status. Winners will
be selected by a random drawing.
Applicable Majors: All Fields of Study
To request an application by mail call (864) 455-8714
or email billy.house@blueridge.coop
To submit your application via email, send to billy.house@blueridge.coop
DEADLINE:
Applicants must be received no later than 5 pm
JULY 6, 2012
Late applications will not be accepted. Winners will be notified by
July 20, 2012. Those not selected will not be notified.
INSTRUCTIONS:
Must complete this form and return along with your essay to the address at the bottom of
this application or email no later than 5 pm on July 6, 2012.
To be considered you must submit all required information by this date.
NAME: (First) _______________________ (Middle) ______ (Last) _________________
DOB: ________________ Email:___________________________________________
ADDRESS:________________________________________________________
CITY____________________________ STATE____________ ZIP ________________
TELEPHONE: (H)(___)___________________(Cell) (___)________________________
NAME OF PARENT:____________________________PHONE:__________________
COLLEGE TO BE ATTENDING:____________________________________________
COLLEGE ADDRESS:___________________________________________________
CITY_____________________________ STATE___________ ZIP________________
HIGH SCHOOL: _________________________________YEAR GRADUATED______
CITY:_________________________________________________ STATE:__________
Checklist: Did you include the following?
A. Completed - Scholarship application form and signature for publicity consent.
B. Essay: “Why I decided to attend college and how I will use my education to help
others”
Applications must be received (mail or email) no later than 5 pm on
JULY 6, 2012
Mail to:
Sabrina House Children’s Charity
P.O. Box 1174
Pickens, SC 29671
Email to: billy.house@blueridge.coop
Publicity Consent
By signing this form, I give my permission for the BI-LO Charities Children's Cancer Center (and/or its
agents) and Sabrina House Children’s Charity to photograph me and/or the following
individuals:_____________________________________________________________
for use in (Check all that apply):
_____ Internal and/or external marketing and public relations activities
_____ External news stories
_____ Internal and/or external education programs
_____ Internal and/or external public displays
_____ The BI-LO Charities Children's Cancer Center and Sabrina House Children’s Charity Web site
_____ Other _________________________
I understand the primary purpose/subject of this photo is to educate or gain awareness regarding the
pediatric cancer treatment center, Sabrina House Children’s Charity. In addition, I give permission for BILO Charities Children's Cancer Center and Sabrina House Children’s Charity to use this photo in a
reasonable manner consistent with the community efforts and mission of Greenville Hospital System.
By signing this form, I waive any and all rights, ownership, and interest in publications, photographs,
and/or recordings resulting from the use of interviews, videos, films, recordings, and/or photographs.
I understand that my permission does not entitle me to any payment, treatment, enrollment in a health plan,
or eligibility for any benefits.
I also agree not to hold BI-LO Charities Children's Cancer Center, Sabrina House Children’s Charity,
and/or their agents responsible for any publicity or any effect whatsoever that may result from the use or
disclosure of this interview, video, film, recording, and/or photo. I may not claim any invasion of my
privacy, any misuse of my likeness, or any other damage to my reputation as a result of my giving my
permission for use or disclosure of this interview, video, film, recording, and/or photo. The permission will
expire when I withdraw my permission in writing.
I certify that I am giving my permission freely and that I may withdraw my permission at any time before
BI-LO Charities Children's Cancer Center, Sabrina House Children’s Charity, and/or their agents take
action based on my authorization.
I understand that giving my authorization to use the interview, video, film, recording, and/or photo being
made is completely voluntary. I understand I may refuse to sign this authorization and that if I refuse, my
decision will not affect my ability to receive treatment at Greenville Hospital System.
I understand I may withdraw my permission to use the interview, video, film, recording, and/or photo being
made at any time by giving GHS written notice and that BI-LO Charities Children's Cancer Center, Sabrina
House Children’s Charity, and/or their agents may continue to use the interview, video, film, recording,
and/or photo unless I withdraw my permission in writing.
Signature of applicant:_____________________________ Date __________,or
Signature of personal representative (if applicant is a minor or unable to sign)
Signature: _______________________________________________Date ____________
Your relationship to the applicant, i.e., parent, guardian, etc.:________________________