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Hemophilia Center of Western New York
Scholarship Application
2014-2015
Name: __________________________________________________________
Address: _________________________________________________________
City: ________________________ State:_____________ Zip:________________
Phone: ______________________ Email:________________________________
Date of Birth: ______________________
Diagnosis:________________________
Current school and grade level: __________________________________________
Name of College, University or Vocational Program you are planning to attend in
fall 2014:
____________________________________________________________________
Class Level (as of fall 2014): _____________________________________________
Anticipated Degree: ____________________________________________________
Anticipated Major: ______________________________________________________
Future Career/Vocation: _________________________________________________
Have you ever been awarded an HCWNY scholarship in the past? Yes or No
If so, when? ________________________________________
*If you received an award last year and are still enrolled in the same degree program, please do not
proceed with the essay questions below. Instead please attach a goals statement about what your
plans are for the next 5 years in order to be considered for an award next fall semester. (Please note
that you will also have to send continued proof of registration, and a current transcript prior to the
start of the 2014-2015 academic year. Also preference will be given to first time applicants. Previous
award winners will only be granted an award if scholarship funds permit).
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Reflective Essay Questions
The following questions will require some thought on your part. Use separate
paper to answer these questions in typed form only.
1) How does your chronic illness affect your life?
2) What are your short term educational and personal goals? Where do you
see yourself in five years?
3) What do you believe makes you unique (describe how you see yourself and
define your strengths and weaknesses)?
4) Have you ever worked very hard or struggled for something and
succeeded? Or failed? Describe that experience and what you gained
from it.
5) In what ways do you contribute to the bleeding disorders/gaucher
community? Are you doing any volunteer work at the present time?
6) Provide any/all information about you and your circumstances the
Scholarship Committee should know as they review your application
(please explain any medical, social, financial, or other obstacles you are
facing at this time that may affect your ability to complete your educational
goals and discuss how the money from the scholarship would be used to
assist you in overcoming those obstacles identified).
Please note - Question 6 is not optional, a response is required!!!
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An official transcript of your grades is required from your institution of higher
education (if applicable) or high school (not both). Send directly to the
Hemophilia Center at the address listed below.
Three (3) written letters of recommendation are required. One of the letters
should be from someone who knows your potential as a student, one from a
current or former place of employment or volunteer work, and one from someone
who knows you personally, other than a relative. They may be sent via email to
msaleh@hemoctr.com or hard copy. If there are any questions, please call (716)
218-4007.
Please have your transcript and hard copy recommendations sent to:
Scholarship Committee
Hemophilia Center of Western New York
936 Delaware Avenue
Buffalo, NY 14209
SCHOLARSHIP INFORMATION
The mission of the Hemophilia Center Scholarship Program is to provide a better
quality of life for individuals affected by Hemophilia, von Willebrand Disease,
Gaucher and other genetic bleeding disorders by awarding financial assistance
for advanced education and training leading to employment and access to health
insurance.
Who is eligible to apply?
Eligible candidates must be patients of the Hemophilia Center of WNY, in good
standing, who are high school seniors, high school (or equivalent) graduates, or
students who are currently enrolled in full-time undergraduate, graduate, or
vocational institutions of higher education. Candidates must have an overall high
school average of 80 or above or a minimum college GPA of 2.5 in order to be
eligible to apply. All recipients are eligible to reapply in subsequent years as long
as they are in good academic standing. This renewal will not be automatic, as
each year’s applicants will be independently evaluated.
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What types of scholarship will be given?
Scholarships will be awarded annually in the categories of vocational,
undergraduate, and graduate programs.
How much are the scholarship awards?
The amount given will be dependent on the number of applicants, the category of
the applicant’s program and the discretion of the Scholarship Committee.
How are the award recipients selected?
The recipients will be chosen on the basis of academic performance, responses
to application questions, participation in school and community activities, work
and/or volunteer experience, recommendations and personal or family
circumstances.
Selection will be based on evaluation of the application and the accompanying
documentation. The Scholarship Committee of the Board of Directors of the
Hemophilia Center of Western New York will be responsible for reviewing and
selecting award recipients. Relatives of committee members or HCWNY staff are
eligible to apply only if they are registered patients of the Hemophilia center.
Scholarship recipients will be expected to complete 12 hours/year of volunteer
service to the Hemophilia Center.
RETURN THE COMPLETED APPLICATION AND ATTACHMENTS BY:
February 15th, 2014.
TO:
SCHOLARSHIP COMMITTEE
HEMOPHILIA CENTER OF WESTERN NEW YORK
936 DELAWARE AVENUE
BUFFALO, NY 14209
(PLEASE NOTE THAT APPLICATIONS RECEIVED LATE OR INCOMPLETE WILL
NOT BE CONSIDERED FOR REVIEW BY THE SCHOLARSHIP COMMITTEE!)
The HCWNY scholarship application is also available on our website at:
www.hemophiliawny.com
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In submitting this application, I certify that the information provided is complete
and accurate to the best of my knowledge. Falsification of information will result
in termination of any scholarship granted.
Applicant’s Signature: ________________________________________________
Date: ____________________________
Hemoshare/Mariam/Scholarship 2014