Academic Scholarship Application

Scholarship Applicant's Name*

First Middle Last

Mailing Address*

Street Address City State ZIP Code

County*

Email*

Primary Phone Number*

Phone Type*

Gender*

Marital Status*

Date of Birth*

MM slash DD slash YYYY

Social Security Number*

# in Household*

Please enter a number greater than or equal to 1.

# of children in household*

18 years old or younger

Name of Transplant Recipient*

First Last

Relationship to Applicant*

Date of Transplant*

MM slash DD slash YYYY

Organ*

Kidney

Pancreas

Heart

Liver

Lung(s)

Transplant Center*

Other

Race (optional)

Other Race

Level of Education (optional)

# of years

Work Status (please choose)

Employer Name

Since (Date)

MM slash DD slash YYYY

Current Source of Income*

Full-Time Employment

Working Spouse

Part-Time Employment

Parent(s) Income

Retirement Pension

SS Retirement

SSDI

SSI

Other

Current Source of Healthcare Coverage*

Insurance

Parent's Insurance

Medicare

Medicaid

QMB Medicaid

Spend-Down Medicaid

COBRA

Other

Insurance Provider

How did you hear about GTF services?*

GTF Website

IMPRINT Magazine or Brochure

GTF Staff

GTF Volunteer

Transplant Center Staff

Other

Name of the person you heard about GTF services from:

School Verification*

School Name

City/State

Date Attended

Date Graduated

GPA

List all high schools, technical schools and colleges which you have attended:

ACT Scores

SAT (reading & math sections) Scores

List school and community activities, special awards, honors, advanced placement classes and leadership positions held:*

Name of institution you plan to attend:*

What degree or certificate are you pursuing:*

Reason for selecting this institution:*

Reason for selecting this career:*

Have you been accepted into this school/program?*

Grade Level*

Expected starting date*

MM slash DD slash YYYY

Expected completion date*

MM slash DD slash YYYY

Projected Cost Per Year

Tuition/Fees*

Housing/Meals*

Books*

Travel*

Total

Scholarships or Grants - List all scholarships/grants that you have been awarded, including HOPE

Name Scholarship

Annual Amount

Scholarship Duration

Do you currently have a student loan?*

Approximate Amount ($)

List others in your household currently in school

Name

Relationship

School (Elem, HS,College)

Expected Date of Completion

Tuition

Total Household Income Per Year*

Consent*

I agree to the following:

I declare that the information reported is true, correct and complete.

Date*

MM slash DD slash YYYY

School Transcripts*

Max. file size: 16 MB.

Upload your official high school transcript (grades 9-12, or Fall semester) OR college/technical school transcript for all courses. GED certificate, if applicable. If your last schooling was more than 5 years ago, current admission testing is acceptable in place of high school transcripts.

Acceptance Letter*

Max. file size: 16 MB.

Upload a copy of the acceptance letter to your current institution.

Student's Personal Statement*

Max. file size: 16 MB.

Maximum of three (3) pages. Describe yourself and how transplantation has affected your life. Tell us something about you that would help us to know you better. You might relate some event that changed your life or beliefs, or an issue about which you have strong feelings. Please tell us about your life goals as they relate to your field of study.

Two (2) Letters of Recommendation*

Drop files here or

Max. file size: 16 MB, Max. files: 3.

At least one of them should be from an academic source. NO letters from relatives or classmates.

URL

This field is for validation purposes and should be left unchanged.

Projected Cost Per Year

Georgia Transplant Foundation

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