Kay/Moore Scholarship Fund

Name

First Last

Gender Identity

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Home Phone

Cell Phone

Social Security # (SSN)

Primary Diagnosis

Date of Diagnosis

Are you on treatment?

Yes

If NO, what's your off treatment date?

Provide a Brief Description of Your Treatment and Current Health

Physician's Name

Treatment Center

Phone

School - GPA/SAT/ACT

Please fill out this section and attach a transcript* signed by a school official.

Grade Point Average (unweighted, based on a 4.0 scale)

Transcript Attached:

Yes

If no, the transcript can be sent by the school directly, emailed to scholarships@specialove.org. School info/transcripts must be for the most recent semester completed. For graduating seniors a high school or undergraduate transcript is acceptable.

Special Love Involvement

Please indicate what Special Love programs you participated in, and years participated.

Camp Fantastic

Years Attended:

Fantastic Friends

Years Attended:

OctoberFest Weekend

Years Attended:

Ski Family Weekend

Years Attended:

Fantastic Winter Weekend

Years Attended:

YAC Weekend

Years Attended:

Tidewater Weekend

Years Attended:

Reunion Weekend

Years Attended:

Summer Family Day

Years Attended:

Virtual Programming

Camp Fantastic 2020

Camp Fantastic 2021

OctoberFest 2020

OctoberFest 2021

David Tutera Spring Craft

David Tutera Fall Craft

David Tutera Winter Craft

Teen Game Night

Terrain Building

Please indicate all the virtual programs and activities you participated in.

Section B: College/University/Trade School Information

Name and address of school to whom you have formally committed and are planning to attend. OR If you have not yet chosen a school, list any to which you have applied. Be aware a scholarship award will not be provided until you have provided evidence of enrollment.

School Name(s) & Address

Student ID # (if different from SSN)

Degree and/or Area of Study:

Is this a graduate level program?

Yes

When is tuition due at the institution? Indicate Fall & Spring Semester's due dates.

Tuition cost per semester:

If not living at home, what is your housing cost per semester:

Average number of credits you plan to take per semester:

Total Credit Hours:

Are you financially independent and responsible for your own cost of living?

If you answered yes, you yourself should complete the financial information.

Do you live with your parent(s)/guardian(s) when not at school?

If you answered yes, your parents/guardians should complete the financial information.

Financial Support

Your application will NOT be reviewed if the information in Section B is incomplete. Applicants who live independently and will cover their own educational expenses should fill out this section themselves in its entirety.

Annual Income:

List sources of income:

Average Monthly Rent Expense:

Average Monthly Utility Expense:

Average Monthly Car Payment Expense:

Average Monthly Insurance Expense:

Average Monthly Food Expense:

Average Monthly Incidentals Expense:

List all scholarships and/or financial aid applied for, noting if they have been approved, or not.

For applicants who live at home, parents/guardians should fill out this section in its entirety.

Annual Gross Household Income:

Do you own your own home?

If YES, what is the value of your home's equity?

(Market value, minus the mortgage balance)

List all outstanding debts over $1,000:

Press the + sign on the right of the field to add more lines.

Will applicant contribute to his/her post-secondary expenses?

If YES, in what way?

Describe any specific information currently influencing your family’s financial need in meeting the applicant’s post-secondary educational costs (i.e. medical bills, loss of job, family illness, etc.):

Section C - Written Essay

Provide a one-page essay on how this scholarship award would help to finance your post-secondary education. NOTE: Applications without a written statement will not be considered January 2022 Essay must include; 1) Why you feel you should be considered for this scholarship 2) Role Special Love played in your treatment and recovery, and; 3) Any residual effects from your cancer. 4) Your planned educational goals You may also attach additional letters of reference at your discretion.

Upload files here:

Max. file size: 8 MB.

Certification(Required)

I agree to the below certification.

I hereby certify all the information provided in this application is true to the best of my
knowledge and that my application is complete and meets the requirements as stated in
the application process.

Kay/Moore Scholarship Fund

2022 Application Process Has Now Closed