Scholarship Application Form Kevin Patoc Scholarship Application Applicant* First Middle Last Current Age*Date of Birth* MM slash DD slash YYYY Gender*SelectMaleFemaleContact DetailsPrimary Phone Number*Secondary Phone NumberEmail* Primary Residence* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Letters of RecommendationYour application requires one letter of recommendation from people who know you well. This letter should be written by someone who can describe your skills, accomplishments and personality. We value these recommendations because they reveal things about you that grades and test scores can't. Please send a request to an individual to provide this information.Letters of Recommendations Files* Drop files here or Select files Accepted file types: pdf, doc, docx, jpg, Max. file size: 512 MB. Diagnosis ConfirmationHave you had or have cancer?* Yes No Does an immediate family member have or has had cancer?* Yes No If yes, who in your family has or had cancer, and what is the relation?*Confirmation of DiagnosisPlease provide a confirmation of diagnosis letter from a medical professional and must be on letterhead from the hospital or doctor's office and must include their contact information in case we need additional information. This letter can be from an oncologist, a primary care physician, or a nurse from the care team. If you do not have immediate access to this letter, please submit without it and we will ask about it later. Please try to get it if possible. Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB. School InformationHigh school or school district that you lived in during high school whether public, private or home schooled?*What year of study will you be in the fall of 2022?*School planning to attend in the 2022/2023 school year? (1st choice if not currently enrolled in college)*State in which the University/College is located*Field of study/Intended major*Career Objective*Cumulative UNWEIGHTED GPA*Note: Please use High School GPA, if college GPA is less than a full year.Income InformationDid you file a tax return in 2020 or 2021?* Yes No Did your parents file a tax return in 2020 or 2021?* Yes No What is your parents filing status for 2021?*College Financial InformationThis section should ideally be completed after you have committed to attend a specific school. This can be either as a continuing student or by submitting your intent to register (SIR) and deposit to the school. Incoming freshman that have not received acceptances and/or submitted their SIR should provide information on their first choice school. Freshman students will be required to update this information when available.Are you attending a new school as either an incoming freshman or transfer student?* Incoming Freshman Transfer Student Full Name of College or University - Please Do Not Abbreviate* (First Choice if undecided)Total Cost of Attendance (COA):(Published by the school - includes tuition, fees, books, room & board, etc)Tuition and Mandatory Fees ONLY:*Expected Family Contribution (EFC) as calculated by FAFSA application (if not filing a FAFSA, use FAFSA4caster accessible here: https://fafsa.ed.gov/FAFSA/app/f4cForm?execution=e1s1)Parent EFCStudent EFCProjected Financial Aid (from FAFSA or FAFSA4caster)Pell GrantOther Grants (CalGrant, TAP, etc):Total amount of other grants or scholarships that are CONFIRMED for the 2021-2022 or 2022-2023 school year:Total Number of family members in your family home*Total Number of siblings in the household attending college in the 2022-23 school year*Transcripts RequestTranscripts from at least TWO full calendar years and cumulative GPA on a 4.0 scale. If less than 2 years in college, please provide HS transcripts AS WELL. UNOFFICIAL transcripts ARE acceptable. Two complete years of transcripts are required. College Freshman will need to provide high school transcripts, college sophomores will need to provide high school and college transcripts, college juniors and college seniors will need to provide college transcripts. Transcripts Files* Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB. Essays and Personal StatementPlease answer the following question (300 - 500 words) as part of your completed application. How has cancer affected your life? Tell us about how cancer has affected you individually or personally? (Physically, Emotionally etc.) How has cancer affected your family? (Is/Was there a financial, psychological or other impact on your family?) How has cancer affected you academically (Did it make academics more challenging? Did it reset your focus to a particular area of study?) Tell us how cancer has led you to make a positive impact on the world around you? Tell us about your community involvement. Essay* Drop files here or Select files Accepted file types: pdf, jpg, Max. file size: 512 MB. Certification Yes, I certify that the above information is truthful and accurate to the best of your knowledge. VerificationUntitledEmailThis field is for validation purposes and should be left unchanged.
