Kids 4 Kids with Cancer Application for Educational Grant

Kids4Kids With Cancer 146 Park Drive San Antonio, TX 78212 [email protected]

KIDS 4 KIDS WITH CANCER APPLICATION FOR EDUCATIONAL GRANT

I. Application Information

Name ______Date of Birth ______Gender ______Address ______City ______State ______Zip ______Phone ______e-mail ______

Reason(s) for applying for grant ______

How did you hear about Kids4Kids? ______

Grant Request from Kids4Kids ______

II. Medical History*

*Kids4Kids With Cancer does not share medical information with any persons or organizations other than the officers and directors of Kids4Kids With CancerPhoto .

Type of Cancer ______Diagnosis Date ______Summary of Treatment ______Kids4Kids With Cancer 146 Park Drive San Antonio, TX 78212 [email protected]

II. Medical History continued

Treating Oncologist(s) ______Hospital or Clinic ______Address ______City ______State ______Zip ______Phone ______e-mail ______

III. Academic Information

School in which you are enrolled/seeking enrollment ______Degree or certificate you are pursuing ______Address ______City ______State ______Zip ______Phone ______Last degree completed ______Date ______

IV. Additional Information (Please attach to application)

• A written narrative (minimum 250 words) telling us how cancer has impacted your life and how you would use your grant from Kids-4-Kids • A doctor’s signed verification letter stating diagnosis

V. Signatures (Required)* *By signing below, applicant and parent/guardian of applicant (if applicable) attest to the truth of the content of the application and agree if a scholarship is awarded to use the full amount of the funds towards the applicant’s stated educational purposes.

Signature of Applicant ______Date______Signature of Parent/Guardian (if under 18 years of age)______Name of Parent/Guardian ______Parent/Legal Guardian Address ______Relationship to student ______Photo and Media Release (attached*)______Kids4Kids With Cancer 146 Park Drive San Antonio, TX 78212 [email protected]

KIDS 4 KIDS WITH CANCER PHOTO AND MEDIA RELEASE

I grant permission to Kids 4 Kids With Cancer to use photographs or other images submitted by me as well as my first name and type of cancer and statements by me concerning Kids 4 Kids for publication including, but not limited to, the K4K website, brochures and newsletters without notifying me.

I agree to waive and release any and all claims against K4K and its officers and directors relating to the images and biographical information and their uses and/or distribution in any version or media.

*Other than using your image and biographical information for promoting Kids 4 Kids non-profit causes, Kids 4 Kids will not sell or knowingly share your personal information to vendors or any individual organization.

I am 18 years of age or older and I am competent to contract in my own name. I have read this release and fully understand the contents and its meaning. (If not 18 years of age or older, Guardian attests to this paragraph on behalf of minor)

Name (Print) ______Signature ______Date ______Signature of Guardian if under 18 years of Age ______