2023 Scholarship Application

ELIGIBILITY
The 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

Save and Continue Later

PERSONAL INFORMATION
Name*
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 State ZIP Code
Home Phone*
College Address
Street Address Address Line 2 City State ZIP Code
College Phone
College Email

Save and Continue Later

FAMILY INFORMATION
Parent/Guardian Information*
First & Last Name Occupation Parent/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.
Dependents
First & Last Name Birth Date Occupation/School School Cost

Save and Continue Later

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/Program Expected 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 [email protected] with your name in the subject line.
Please email your transcript no later than April 1st to [email protected] with your name in the subject line.
GOALS*
Write a statement of your educational or career goals.

Save and Continue Later

FINANCIAL INFORMATION
Parents' Total Annual Income:*
Applicant's Annual Income:*
(Most recent tax return(s) may be requested)

Save and Continue Later

CURRENT EDUCATIONAL COST & SUPPORT (2022-23)
If you are currently attending college, please complete the following:
TOTAL EDUCATIONAL COST FOR 2022-23:
AMOUNT OF FINANCIAL SUPPORT RECEIVED FROM:
Parents/Relatives:
Scholarships/Grants:
Loans:
Self:
Other:
TOTAL Financial Support:
TOTAL AMOUNT OF LOANS OUTSTANDING:

Save and Continue Later

ANTICIPATED EDUCATIONAL COST & SUPPORT (2023-24)
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)

Save and Continue Later

OTHER INFORMATION
2023 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 [email protected] 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 [email protected] 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 [email protected] with your name in the subject line.
Please email your Doctor's Statement no later than April 1st to [email protected] with your name in the subject line.
How did you become aware of The Susan Fund Scholarship Program?*

Save and Continue Later

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.
File
Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.
File
Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.
File
Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.
File
Accepted file types: pdf, jpg, jpeg, gif, png, Max. file size: 100 MB.

Save and Continue Later

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 [email protected] with your name in the subject line.
Please email your photo no later than April 1st to [email protected] 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.

Save and Continue Later

Applications and all supporting documents must be submitted no later than April 1, 2023. Must be a resident of Fairfield County, Connecticut.

Step 1 of 10

ELIGIBILITY

The 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:

PERSONAL INFORMATION

FAMILY INFORMATION

EDUCATIONAL INFORMATION

FINANCIAL INFORMATION

CURRENT EDUCATIONAL COST & SUPPORT (2022-23)

ANTICIPATED EDUCATIONAL COST & SUPPORT (2023-24)

OTHER INFORMATION

VERIFICATION AND RELEASE

First & Last Name	Occupation	Parent/Guardian Email

First & Last Name	Birth Date	Occupation/School	School Cost

School/Program	Expected Year of Graduation