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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!!!"
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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 current,
active enrollment in a qualified institution.
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ATTENTION APPLICANTS!
Please review our ELIGIBILITY requirements before applying! PREVIOUS WINNERS ARE NOT ELIGIBLE. Your cancer 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 CURRENTLY ENROLLED in college or a qualified post-secondary program, and must
submit proof of enrolment from your college in the form of a letter. (NOTE TO HIGH SCHOOL SENIORS: you must provide
written confirmation of your planned attendance from your selected college - such as a receipt for a deposit).
An actual transcript is not required. 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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