Applications and all supporting documents must be submitted no later than April 1, 2022. Must be a resident of Fairfield County, Connecticut. Step 1 of 10 10% ELIGIBILITYThe Susan Fund is dedicated to assisting Fairfield County residents, who have been diagnosed with cancer, to pursue their educational goals through scholarship grants. Applicants must meet all three of the following criteria to be considered for a Susan Fund scholarship:* Be a current resident of Fairfield County, Connecticut * Have been diagnosed with cancer at some time in one's life * Be planning/attending an accredited post high school institution of higher learning PERSONAL INFORMATIONName* First Middle Last Birth Date* Month Day Year Cell Phone*Preferred Email* Best method to contact you:* Text cell phone Preferred email Home Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone* College Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code College PhoneCollege Email FAMILY INFORMATIONParent/Guardian Information*First & Last NameOccupationParent/Guardian Email Please enter information for all parents and/or guardians. Use the "+" button to add additional parents or guardians. List brothers, sisters or other relatives who are financially dependent upon your parents or yourself. DependentsFirst & Last NameBirth DateOccupation/SchoolSchool Cost EDUCATIONAL INFORMATION List institution now attending, or college, institutions or training programs to which you have applied or plan to apply, in order of preference, and the expected year of graduation.*School/ProgramExpected Year of Graduation SCHOOL TRANSCRIPT Your most recent school transcript from High School or College is required as part of your application. The transcript can be uploaded and attached to this application by choosing the upload delivery method below. If you are unable to upload your Letter of Recommendation at this time, please choose the email option below for instructions to send your recommendation later.Delivery Method* Upload Transcript Email Transcript Upload School Transcript*Must be a PDF, JPG, JPEG, GIF or PNG file.Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.If unable to upload your transcript at this time, please click on the "Email Transcript" option above and email it to SUSANFUND@GMAIL.COM with your name in the subject line. Please email your transcript no later than April 1st to SUSANFUND@GMAIL.COM with your name in the subject line. GOALS*Write a statement of your educational or career goals. FINANCIAL INFORMATIONParents' Total Annual Income:* Applicant's Annual Income:* (Most recent tax return(s) may be requested) CURRENT EDUCATIONAL COST & SUPPORT (2021-22)If you are currently attending college, please complete the following: TOTAL EDUCATIONAL COST FOR 2021-22: AMOUNT OF FINANCIAL SUPPORT RECEIVED FROM: Parents/Relatives:Scholarships/Grants:Loans:Self:Other:TOTAL Financial Support: TOTAL AMOUNT OF LOANS OUTSTANDING: ANTICIPATED EDUCATIONAL COST & SUPPORT (2022-23) ANTICIPATED EDUCATIONAL EXPENSES FOR THE COMING YEAR: Tuition:*Room:*Board:*Books:*Supplies:*Travel:*TOTAL Anticipated Expenses (A):* AMOUNT OF FINANCIAL SUPPORT YOU EXPECT FROM: Parents:*Relatives:*Scholarships:*Loans:*Self:*Other:*TOTAL Financial Support (B):* *Note: Total Anticipated Expenses (A) MUST EQUAL Total Financial Support (B) OTHER INFORMATION2022 LETTER OF RECOMMENDATION (a new one is required every year) A current letter of recommendation from your employer or school authority is required as part of your application. The letter can be uploaded and attached to this application by choosing the upload delivery method below. If you are unable to upload your Letter of Recommendation at this time, please choose the email option below for instructions to send your recommendation later.Delivery Method* Upload Letter of Recommendation Email Letter of Recommendation Upload Letter of Recommendation*Must be a PDF, JPG, JPEG, GIF or PNG file.Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.If unable to upload your Letter of Recommendation at this time, please select the "Email Letter of Recommendation" option above and ask your Recommender to email it to SUSANFUND@GMAIL.COM no later than April 1st with your name in the subject line. Please email or ask the Recommender to email your Letter of Recommendation no later than April 1st to SUSANFUND@GMAIL.COM with your name in the subject line. Describe your work and volunteer experience over the past 12 months:* Describe your family's financial circumstances:* MEDICAL INFORMATION - Please explain the nature of your illness:*If you are a first time applicant, you must submit a statement from your doctor describing the nature of your illness. Past recipients are encouraged to submit a current doctor's statement. Please choose one of the delivery methods below or indicate that you will not be submitting a doctor's statement. Delivery Method* Upload Doctor's Statement Email Doctor's Statement Not required to submit a Doctor's Statement Upload Doctor's Statement*Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.Must be a PDF, JPG, JPEG, GIF or PNG file.If unable to upload your Doctor's Statement at this time, please select the "Email Doctor's Statement" option above and email it no later than April 1st to SUSANFUND@GMAIL.COM with your name in the subject line. Please email your Doctor's Statement no later than April 1st to SUSANFUND@GMAIL.COM with your name in the subject line. How did you become aware of The Susan Fund Scholarship Program?* You or your parents are encouraged to include any additional pertinent data in support of your application. Documents can be uploaded by clicking on the "Choose File" buttons below. Must be a PDF, JPG, JPEG, GIF or PNG file. FileAccepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.FileAccepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.FileAccepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.FileAccepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB. VERIFICATION AND RELEASE CURRENT PHOTO Please submit a current photo.Delivery Method* Upload Photo Email Photo Must be a JPG, JPEG, GIF or PNG file.*Accepted file types: jpg, gif, png, jpeg, Max. file size: 100 MB.If unable to upload your photo at this time, please select "Email Photo" and email it no later than April 1st to SUSANFUND@GMAIL.COM with your name in the subject line. Please email your photo no later than April 1st to SUSANFUND@GMAIL.COM with your name in the subject line. Applicant's Electronic Signature*Hold cursor button down and use cursor to draw your signature.Date* MM slash DD slash YYYY Electronic Signature Acceptance* I ACCEPT By entering your Name and Date and checking off the "I ACCEPT" box below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. PUBLICITY AUTHORIZATION The recipient of a Susan Fund scholarship understands that receiving such a grant may result in publicity, and hereby authorizes The Susan Fund to publicize or use the recipient’s name and/or photograph, now or in the future, in promotional material involving The Susan Fund. The recipient hereby releases and holds harmless The Susan Fund and its Board of directors from any and all liabilities, damages or claims of any kind resulting from the use, distribution of disclosure of the recipient’s name and/or photograph or other information regarding the recipient. Applicant's Electronic Signature*Hold cursor button down and use cursor to draw your signature.Date* MM slash DD slash YYYY Electronic Signature Acceptance* I ACCEPT By entering your Name and Date and checking off the "I ACCEPT" box below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement.
