Sacks for cf scholarship

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Personal Information

Name Last M.I. First

Street Address City State ZIP E-mail

CF Center College Attending/Will Attend

Telephone (home/cell) Date of Birth/Age Male/Female

Country of Citizenship Social Security Number

Have you ever been convicted of a crime? If yes, explain on separate page.

Family Information

Father’s name Mother’s name

Father’s profession Mother’s profession

Number of siblings Number of siblings w/CF Siblings’ ages

Have you applied for a BEF scholarship before? Yes_____ No ____

Did you receive one? Yes_____ No____

Education Information

Name of High School City State Overall G.P.A. Rank in Class

Name of Undergraduate College City State Overall G.P.A. Declared Major

Name of Graduate College City State Overall G.P.A. Declared Major

On a separate sheet please list…

All school activities you have participated in (including sports/club sports)

Activity Number of Yrs. Awards/Honors Offices Held

All community activities that you have participated in without pay (civic involvement, volunteer work, etc.)

Organization Number of Yrs. Awards/Honors Describe Involvement

History of employment

Company Position Dates Average hrs./week Salary

Essay Topic (2 parts)

  1. Discuss the importance of compliance to CF therapies and what you practice on a daily basis to stay healthy.

  1. Discuss your postgraduation goals.

(Limit essay to 2 double-spaced pages)

Applicants must provide ALL of the following.
Incomplete applications will NOT be considered.

Please check to ensure you send the application in its entirety.
Completed and signed application

Recent photo of yourself for identification purposes

Letter from your doctor confirming diagnosis of cystic fibrosis

and a list of your daily medications

2-part essay

An official or unofficial high school/college transcript

Tuition breakdown (including housing, dining, etc.)

W2 form for verification for both parents

I certify that the information presented in my application is accurate and complete. I understand and agree that any inaccurate information, misleading information, or omission will be cause for the rescission of any grant offered to me. BEF may verify any and all of my application materials.

Date: ___________ Applicant’s signature: __________________________
Please mail completed application and forms to:
Boomer Esiason Foundation, Scholarship Program,
483 10th Avenue, Suite 300, New York, New York, 10018

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