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RYAN MULLALY SECOND CHANCE FUND
Confidential Application
Name:_______________________________
Address:_____________________________
____________________________________
____________________________________
Email Address:________________________ **Please print clearly as we use this address to contact
you
Phone:_______________________________
U.S. Citizen/Permanent Resident? ______
Date
of Birth:_________________________
Diagnosis:____________________________
Age at Diagnosis:_______________________
Doctor:______________________________
Hospital:_____________________________
Treatment Protocol(s)_________________
______________________________________
______________________________________
Current School:________________________
Grade:________________________
Major:_______________________________
Expected Graduation Date:______________
Are you employed? Yes ( ) No ( )
Full-time ( ) Part-time ( )
Name & Address of Employer:____________
____________________________________
____________________________________
Family Information
Number of Siblings and Age(s)____________
____________________________________
Father: Alive ( ) Deceased
( )
Address:_____________________________
____________________________________
____________________________________
Occupation:___________________________
Mother: Alive ( ) Deceased ( )
Address:_____________________________
____________________________________
____________________________________
Occupation:__________________________
Do you have any dependents? If so, list
ages:________________________________
Have you been awarded
any other scholarships or financial aid? If so, please list the source and amount of each award:
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
____________________________________
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Ryan's Mom says....... "WE DON'T WANT YOUR TAX RETURNS... WE DON'T NEED
YOUR SAT'S.. DON'T SEND STUFF UNLESS IT'S ASKED FOR... FOLLOW THE DIRECTIONS, PLEASE!!!" DEADLINE FOR APPLICATIONS is JULY 31, 2012
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PLEASE
REVIEW OUR ELIGIBILITY REQUIREMENTS CAREFULLY BEFORE APPLYING, AND BE SURE TO SEND ALL REQUIRED DOCUMENTATION WITH YOUR APPLICATION
IN ONE ENVELOPE. INCOMPLETE APPLICATIONS CANNOT BE CONSIDERED.
On a separate piece of paper, please submit an essay
telling us about yourself. Please include a detailed description of your cancer diagnosis, treatment and experience. Tell
us how cancer changed your outlook on life for the better or worse, and how it impacted your high school years. Discuss your
academic and professional goals and dreams for your future. Describe any volunteer work, awards, extracurricular activities,
hobbies, and anything else you are especially proud
of.
Include a letter from your treating oncologist confirming
your diagnosis and treatment, and proof of acceptance and/or enrollment in a qualified institution.
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ATTENTION APPLICANTS!
Please review our ELIGIBILITY
requirements before applying! PREVIOUS WINNERS ARE NOT ELIGIBLE. Your lymphoma diagnosis or recurrence must have occurred
between the ages of 13 and graduation from high school, and you must have undergone treatment for cancer while in high school.
You must be accepted into college or a qualified post-secondary program, and must submit proof of acceptance and intent to
enrol from your college in the form of a letter from the school or a a deposit receipt.Please do not send partially completed
applications...we cannot consider your application until all the required documents are sent (your treating oncologist's letter,
your essay, your school's letter confirming enrolment and your application).
MAIL your completed application
form, proof of school enrolment, essay and treating oncologist's letter to us at 26 Meadow Lane, Pennington, New Jersey 08534.
DUE TO PAST PROBLEMS, WE ARE NO LONGER ACCEPTING EMAILED DOCUMENTS.
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