2015 CHAPTER SCHOLARSHIP APPLICATION National Multiple Sclerosis Society New Jersey Metro Chapter

Transcription

1 2015 CHAPTER SCHOLARSHIP APPLICATION National Multiple Sclerosis Society New Jersey Metro Chapter The Chapter Scholarship program has been established to assist students who are affected by multiple sclerosis, either by having MS themselves or having a parent with MS. Application: - Applications will be available starting December 1, All applications must be thoroughly completed and postmarked no later than February 13, Incomplete applications or those lacking documentation will not be considered. - Students will be notified of decisions in May For any questions, contact Patti at or patti.pasquino@nmss.org Eligibility Requirements: Please read carefully to ensure eligibility - Have a parent with MS or be a student with MS. - Provide documentation of MS diagnosis (note from doctor). - The parent with MS or student with MS must live within the Chapter s service area: Bergen, Essex, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset, Sussex, Union & Warren Counties. - Submit current proof of residency of the person with MS (i.e. utility bill) and the first page of their most recent 1040 income tax return form. If the person with MS is still considered a dependent we will need their parents most recent 1040 income tax return form. - Full-time student engaged in undergraduate programs (freshman-senior yrs.), or post high school studies in the Fall of Compose an essay as per the question on the application. - Previous awardees cannot receive an award for more than 5 years. Selection Procedures: Funding requests are approved according to our available funds, as well as your financial needs and special circumstances. Families with limited resources will be given first priority. Post-Application / Award Recipients: Those who are determined eligible for an award are required to submit proof of full-time registration for the Fall 2015 semester, before funds can be administered.

2 The application must be submitted to the Chapter office via mail, or fax Mail: National Multiple Sclerosis Society New Jersey Metro Chapter 1480 U.S. Highway 9 North, Suite #301 Aspen Corporate Park, Building 1 Woodbridge, NJ Attention: Patti Pasquino patti.pasquino@nmss.org Fax: or Please Note: This is the Chapter Scholarship Program, which is separate from the National Scholarship Program. New & returning applicants must complete this 2015 application. Information about Applicant: Name: Address: City: State: Zip: County: Telephone: (daytime) Date of Birth: How many years have you applied for this program? Please list the years in which you received an award for this program: Name & Information of Parent with MS: Include the 1040 form, and current proof of residency with application, i.e. copy of utility bill. (Please just write Self if applicant has MS) Name: Address: City: State: Zip: Telephone: (daytime) Relationship to applicant:

3 1. What level of post-secondary education will you be at in Fall 2015? Check one: Freshman Sophomore Junior Senior Other (Please state): 2. Secondary school last attended (Name and Town): 3. Please state the name and address of the educational institution(s) you will be attending, or have applied to for the Fall of 2015: 4. Please state your income and note any changes in your income from the most recent 1040 you are submitting. 5. How many persons live in your household? 6. How many persons in the household will be attending post-secondary education in Fall 2015, including yourself? 7. If you receive this scholarship, what will the money be used for? Tuition Books Room/Board Other 8. How do you plan to finance your education? 9. Have you or your family received financial assistance from the Chapter this past year?

4 ESSAY: Write an essay responding to the question(s) below. The essay is intended to let us know more about you, and why you would be a good candidate for the Chapter Scholarship. It is also a good time to inform us of any special circumstances that we should be aware of. Limit your response to two pages. Please note: First time applicants and returning applicants have different essay questions. FIRST TIME APPLICANTS - Share your educational experience and your extra curricular activities, whether in school or in the community. What are you majoring in or planning to major in and why? How has having an MS diagnosis in your life impacted your educational goals? Share any challenges you face. RETURNING APPLICANTS - If you have previously been awarded an MS Scholarship, please update us on your academic year and activities, how the funds assisted you, any ongoing challenges. Do not submit the same essay as last year, as we will not be able to consider your application. I certify that the information I have given is true and correct. Applicant Signature Date

5 PHOTO AND MEDIA RELEASE NATIONAL MULTIPLE SCLEROSIS SOCIETY NEW JERSEY METRO CHAPTER CHAPTER SCHOLARSHIP PROGRAM I hereby give permission to the National Multiple Sclerosis Society and the New Jersey Metro Chapter to use my name, town, name of high school that I am graduating from, and college that I am attending, and any photograph taken of me in any promotional materials and publications; including but not limited to the Chapter s website and newsletter, as well as the public media. I certify that I have read this waiver and release and understand its significance. Print Name Signature Date Signature of Parent if under 18 years of age Signature Date