Memorial Scholarship Programs
Application Checklist
! Completed, signed and dated Application
! A recent, wallet-sized Photograph of yourself
! Letter of Verification from hematologist, physician or treatment center.
Treatment center or physician-signed hemophilia “travel” letter is acceptable
! Copy of most recent Transcripts from high school and college/university/technical school (if
already attending). Transcripts do not need to be certified copies
! Copy of ACT or SAT scores (Required for incoming freshman only)
! 300 to 400 word Essay
! Letter of Recommendation from a teacher, instructor, professor or school administrator
(Copy of recommendation letter acceptable)
! Letter of Recommendation from employer, church leader, volunteer coordinator, etc.
(Copy of recommendation letter acceptable)
! Proof of Admission to the college/university/technical school
(Required for incoming freshman only)
! Signed and dated Release
! Affix appropriate postage and submit. Must be postmarked before the August 1st deadline
Incomplete or late applications will not be eligible for consideration. Please mail your complete
scholarship application packet to:
Matrix Health Group Memorial Scholarship Programs
c/o Maria Vetter
2202 Brownstone Court; Champaign, IL 61822
For questions, please call, text or email Maria Vetter: 217-840-1033; maria.vetter@matrixhealthgroup.com
Memorial Scholarship Programs
Application Form - page 1
Program Selection:
Please review the scholarship requirements and indicate the program(s) for which you are applying.
Check all that apply - no need to submit separate applications for each program.
! Matrix Health - Joe Holibaugh Memorial Scholarship:
For MEN or WOMEN with hemophilia and an inhibitor.
! Matrix Health - Tim Kennedy Memorial Scholarship:
For MEN with hemophilia
! Factor Support Network - Millie Gonzalez Memorial Scholarship:
For WOMEN with hemophilia or von Willebrand Disease
! Factor Support Network - Mike Hylton Memorial Scholarship:
For MEN with hemophilia or von Willebrand Disease and their immediate family members
! Factor Support Network - Ron Niederman Memorial Scholarship:
For MEN with hemophilia or von Willebrand Disease and their immediate family members
! Homecare for the Cure – Mark Coats Memorial Scholarship:
For MEN and WOMEN with a bleeding disorder and their immediate family members
Personal Information:
Last Name ________________________ First Name _____________________ Middle Initial______
Address ____________________________________ Home Phone __________________________
_____________________________________ Cell Phone __________________________
Email Address _____________________________________________________________________
Date of Birth ________________________
Bleeding Disorder
! Hemophilia A
! Male
! Hemophilia B
! Female
! von Willebrand –Type ______________
! Other __________________________________________________________________________
Severity ! Mild
! Moderate
! Severe
! Inhibitor
Age at diagnosis _____________
Physician Name and Phone Number ____________________________________________________
Hemophilia Treatment Center (if applicable)_______________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Memorial Scholarship Programs
Application Form - page 2
Educational Information:
High School Attended ______________________________ City and State ______________________
Graduation Date ________________ ACT or SAT Score (if incoming freshman) __________________
Cumulative High School (or current college/school) Grade Point Average _______ Grading Scale_____
What has been your favorite subject? ___________________________________________________
What has been your least favorite subject? _______________________________________________
Plan on attending, or are attending: ! Graduate School
! Technical/Trade
! University/College
! Jr. College
! Other ____________________________
School ____________________________________________________________________________
City, State _________________________________________________________________________
Have you been formally accepted? ! Yes
Field of Study
! No
Major _______________________________________________________________
Minor (if applicable) ____________________________________________________
At the beginning of the next school year, what year will you enter?
! Freshman
! Sophomore
! Junior
! Senior
! Graduate Student
Expected year of graduation or program completion ____________
Scholarship:
How did you hear of the Matrix Health Group Memorial Scholarship programs?
! Matrix Health Group News newsletter
! Face Book
! Direct mailing
! Online Scholarship Listing (please name) _____________________________________________
! Matrix Health Group personnel (please name) __________________________________________
! Chapter or Foundation (please specify) ________________________________________________
! HTC Personnel (please name) ______________________________________________________
! Other (please specify) _____________________________________________________________
Memorial Scholarship Programs
Application Form - page 3
Work Experience:
Please list any jobs you have held, your job title, duties and dates of employment.
A resume or additional sheet may be substituted for this section.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Volunteer Experience:
Please list any volunteer positions you have held.
A resume or additional sheet may be substituted for this section.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Hobbies and Activities:
Please list any hobbies or activities you enjoy.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Essay:
Please choose one topic and submit a typed essay of 300-400 words. Please attach as a separate
sheet and sign your name at the bottom of your essay.
1.) Tell us about experiences that have influenced your decision to pursue your educational
goals or career choice
2.) Tell us how you feel your life has been influenced by having a bleeding disorder (or by having a
bleeding disorder in your family)
3.) What has been your biggest challenge in regards to having a bleeding disorder and how have you
or are you working through it?
Memorial Scholarship Programs
Application Form - page 4
Certification and Release
Applications received by the Matrix Health Group Memorial Scholarship Programs will be reviewed and
winners will be determined by a Scholarship Committee. All decisions made by the Scholarship
Committee are final. It may be necessary for someone from the Scholarship Committee to contact you
directly for a personal interview or to qualify any information contained in this application.
I have personally signed this Matrix Health Group Memorial Scholarship Programs application. I certify
that all statements contained in the foregoing application are true and correct.
In consideration of my acceptance of this scholarship, should I be selected as an award recipient, I
agree to all the conditions set forth, and further agree to grant all permission to Matrix Health Group, its
companies and the Memorial Scholarship Programs, to any and all the foregoing, to use any
photographs, quotes contained herein, and statements for use in social media, publications, website,
promotional materials and advertising for any purpose of announcing the scholarship and its recipients.
____________________________________________
Printed Name
____________________________________________
Signed Name
______________________________
Date
If applicant is under age 18, please include a parent or guardian’s signature
_____________________________________________ ______________________________
Parent or Guardian Printed Name
Phone Number
_____________________________________________ ______________________________
Parent or Guardian Signed Name
_____________________________________________
Basis of Authorization
Date
Memorial Scholarship Programs
RECOMMENDATION FORM
Teacher, Instructor, Professor or School Administrator
Dear Applicant: Please fill out your name and address on this form and give it to the person you have
requested to submit your recommendation. A signed letter of recommendation may be substituted for
this form or attached as additional information. It is your responsibility to see that the recommendation
is submitted by the August 1st deadline.
Recommendation:
Name of Applicant ___________________________________________________________________
Address of Applicant _________________________________________________________________
What is your relationship to the above applicant? ___________________________________________
__________________________________________________________________________________
How long have you known the applicant? ________________________________________________
What are the applicant’s most significant talents? Please continue on reverse side or attach a letter.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________
________________________________
Email address
Phone number
_______________________________________________
Printed Name
_______________________________________________
_________________________________
Signed Name
Date
Please return this form to the student for mailing by the August 1st deadline.
You may also mail your recommendation directly to the Scholarship Committee:
Matrix Health Group Memorial Scholarships Program
c/o Maria Vetter
2202 Brownstone Court; Champaign, IL 61822
For questions, please call, text or email Maria Vetter: 217-840-1033; maria.vetter@matrixhealthgroup.com
Memorial Scholarship Programs
RECOMMENDATION FORM
Employer, Volunteer Coordinator, Church Leader, Etc.
Dear Applicant: Please fill out your name and address on this form and give it to the person you have
requested to submit your recommendation. A signed letter of recommendation may be substituted for
this form or attached as additional information. It is your responsibility to see that the recommendation
is submitted by the August 1st deadline.
Recommendation:
Name of Applicant ___________________________________________________________________
Address of Applicant _________________________________________________________________
What is your relationship to the above applicant? ___________________________________________
__________________________________________________________________________________
How long have you known the applicant? ________________________________________________
What are the applicant’s most significant talents? Please continue on reverse side or attach a letter.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
_______________________________________________
________________________________
Email address
Phone number
_______________________________________________
Printed Name
_______________________________________________
_________________________________
Signed Name
Date
Please return this form to the student for mailing by the August 1st deadline.
You may also mail your recommendation directly to the Scholarship Committee:
Matrix Health Group Memorial Scholarships Program
c/o Maria Vetter
2202 Brownstone Court; Champaign, IL 61822
For questions, please call, text or email Maria Vetter: 217-840-1033; maria.vetter@matrixhealthgroup.com
Memorial Scholarship Programs
MEDICAL VERIFICATION FORM
Physician or Treatment Center
Dear Applicant: Please fill out your name and address and give this form to your physician or
hemophilia treatment center. A copy of a letter signed by your physician or treatment center (such as a
travel letter) verifying your bleeding disorder may be substituted for this form. It is your responsibility to
see this form is submitted by the August 1st deadline.
Name of Applicant __________________________________________________________________
Address of Applicant _________________________________________________________________
To be completed by applicant’s Physician or Nurse
What type of bleeding disorder has this scholarship applicant been diagnosed with?
! Hemophilia A
! Hemophilia B
! von Willebrand ! Type 1
! Type 2
Severity:
! Mild
! Moderate
Inhibitor:
! Yes
! No
! Type 3
! Severe
Severity___________________________
! Other (please specify)_____________________________________________________________
____________________________________________________
____________________________
Physician/Nurse Signed Name
Date
____________________________________________________
____________________________
Physician/Nurse Printed Name
Phone number
____________________________________________________
Treatment Center or Medical Facility
__________________________________________________________________________________
Treatment Center or Medical Facility Address
Please return this form to the student for mailing by the August 1st deadline.
You may also mail the Medical Verification directly to the Scholarship Committee:
Matrix Health Group Memorial Scholarship Programs
c/o Maria Vetter
2202 Brownstone Court; Champaign, IL 61822
For questions, please call, text or email Maria Vetter: 217-840-1033; maria.vetter@matrixhealthgroup.com