<p> Kids4Kids With Cancer 146 Park Drive San Antonio, TX 78212 [email protected]</p><p>KIDS 4 KIDS WITH CANCER APPLICATION FOR EDUCATIONAL GRANT</p><p>I. Application Information </p><p>Name ______Date of Birth ______Gender ______Address ______City ______State ______Zip ______Phone ______e-mail ______</p><p>Reason(s) for applying for grant ______</p><p>How did you hear about Kids4Kids? ______</p><p>Grant Request from Kids4Kids ______</p><p>II. Medical History*</p><p>*Kids4Kids With Cancer does not share medical information with any persons or organizations other than the officers and directors of Kids4Kids With CancerPhoto .</p><p>Type of Cancer ______Diagnosis Date ______Summary of Treatment ______Kids4Kids With Cancer 146 Park Drive San Antonio, TX 78212 [email protected]</p><p>II. Medical History continued</p><p>Treating Oncologist(s) ______Hospital or Clinic ______Address ______City ______State ______Zip ______Phone ______e-mail ______</p><p>III. Academic Information </p><p>School in which you are enrolled/seeking enrollment ______Degree or certificate you are pursuing ______Address ______City ______State ______Zip ______Phone ______Last degree completed ______Date ______</p><p>IV. Additional Information (Please attach to application)</p><p>• 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 </p><p>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. </p><p>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]</p><p>KIDS 4 KIDS WITH CANCER PHOTO AND MEDIA RELEASE</p><p>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.</p><p>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.</p><p>*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.</p><p>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)</p><p>Name (Print) ______Signature ______Date ______Signature of Guardian if under 18 years of Age ______</p>