YOUNG CANCER SURVIVOR SCHOLARSHIP PROGRAM

2009-2010
American Cancer Society, California Division, Inc.
1710 Webster St.  Oakland, California  94612

The Young Cancer Survivor Scholarship Program What is expected of Young Cancer Survivor Scholarship
The American Cancer Society, California Division, Inc.’s recipients?
Young Cancer Survivor Scholarship Program is a  Scholarship recipients are expected to demonstrate
scholarship program that awards stipends of up to behavior consistent with the American Cancer
$7500 per academic year to college bound or enrolled Society’s Volunteer and Staff Code of Ethics
young cancer survivors in need of financial aid. The  Scholarship recipients are required to maintain full-
awards are to be used for tuition-related expenses at time status in order to receive funds. Full-time status
accredited 2 or 4 year undergraduate institutions of is defined as at least 12 units per semester or
higher education located in California. quarter. A note from the doctor is required if the
student cannot maintain a 12 unit schedule.
Why is the American Cancer Society, California  Scholarship recipients are required to serve a
Division, Inc. offering a Young Cancer Survivor minimum of twenty-five volunteer hours with the
Scholarship Program? American Cancer Society. Opportunities for
The Young Cancer Survivor Scholarship Program volunteerism include:
advances the California Division’s goal of improving the  serving as an ACS spokesperson
quality of life of cancer patients and their families by:  participating in fundraising / awareness events
 improving the capacity of young cancer survivors to such as Relay for Life; Daffodil Days
attend college,  legislative advocacy
 reducing the financial impact of college attendance  helping to initiate or maintain Colleges Against
on the cancer survivor’s family. Cancer programs
 many more!
Who is eligible to apply for the Young Cancer
 Scholarship recipients may be asked to communicate
Survivor Scholarship Program?
with American Cancer Society donors and/or
College bound or enrolled students who are:
program administrators.
 cancer survivors diagnosed at 18 years or younger
 Scholarship recipients are expected to attend a
 age 25 or younger at the time of application
scholarship awards luncheon sponsored by the
 able to demonstrate financial need
California Division.
 California residents
 planning to attend or are attending a 2 or 4 year What criteria are used in evaluating Young Cancer
accredited undergraduate institution of higher Survivor Scholarship applications?
education in California.  financial need
 medical hardship
What restrictions are there on the use of Young Cancer
 determination, motivation, and educational goals
Survivor Scholarships?
 academic requirements (minimum 2.5 GPA)
Scholarships may be used for enrollment and  community service
attendance tuition, fees, health insurance, books, and In addition to financial need and basic academic
supplies required for course instruction in accredited requirements, the evaluation panel is interested in the
undergraduate institutions of higher education located applicant’s educational and career plans, life philosophy
in California. Personal expenses, transportation, and and volunteerism, motivation and determination.
room and board are not covered. Scholarship awards Applicants are asked to describe these through three
are determined by the individual’s school, based on short essays.
demonstrated financial need, and are paid directly to
Renewal of Scholarship Awards
the institution. Awards must be used during the
Applicants awarded scholarships are eligible to reapply
academic year in which they are granted. Any unused
to the program for up to a total of four years including
funds are returned to the California Division of the
the initial academic award period. Renewal applicants
American Cancer Society.
must submit a separate Renewal Application available
from the Division office. Renewal of this award is
neither automatic nor guaranteed.

** Due to limited resources, the American Cancer Society is not able to award scholarships to all
young cancer survivors who apply.

www.cancer.org 1-800-ACS-2345
2009-2010 APPLICATION PROCEDURES
American Cancer Society, California Division, Inc.
Young Cancer Survivor Scholarship Program

1) Application Form 5) Official Grade Transcripts

All information on the 2009-2010 Application Form must You must submit an official transcript(s) showing final
be completed in order for your application to be grades for all courses taken from 9th grade to your present
considered. If any information or items are missing, your or most recently completed semester (high school and
application will not be considered. college coursework). These documents must be included in
your application package and MUST have official
2) Free Application for Federal Student Aid (FAFSA) signatures and/or a school seal. Unofficial transcripts will
STUDENT AID REPORT (SAR) you receive based on the not be accepted.
information you provided in your FAFSA Student Aid
Report For more information about receiving a free FAFSA, 6) Proof of Cancer Diagnosis
visit www.fafsa.ed.gov or call 1-800-4-FED-AID / TTY 1-800- A letter from your oncologist confirming your cancer
730-8913. These can take some time to process, so allow diagnosis MUST accompany your application packet. The
plenty of time. letter should:
 be written on your oncologist’s letterhead,
3) Personal Statements
 include the type of cancer with which you were
Please answer questions a, b, and c. Each answer should be
diagnosed,
typed, have a maximum of 250 words, and be clearly
labeled with the corresponding titles: “Goals,” “Life  include the last treatment date and whether or not
Experience,” and “Community Service.” Use your own treatment is completed,
voice and writing style.*Include your complete name in the  include your oncologist’s signature and daytime
upper right hand corner of each page. Incomplete, missing, telephone number.
or unmarked essays will inactivate your application. The content of this letter can be incorporated into the
a. Goals required letter of reference from one of your
Describe your education and/or training plans immediately comprehensive health team members so long as all items
following high school and describe possible career for both the proof of diagnosis and the letter of reference
goals/plans. requirements are met.
b. Life Experience
Please describe how courage, self-reliance, and/or
7) Quotable and Photo
Please tell us in 75 words or less what being awarded with
determination have affected your life to this point and
the scholarship would mean to you. Email this portion of
how you feel life experiences can help prepare you to
the application to: [email protected]. Put in the
reach your future goals.
subject line of the email re: scholarship quotable, your full
c. Community Service
name, and the academic year for which you are applying.
Describe any volunteer work you have done to benefit
Also include an electronic head and shoulders photo of
individuals, groups, nonprofit organizations, agencies,
yourself with this email.
schools, or the community at large. Include mention of any
awards or recognition received. 8) Preparing your Application Package
All portions of the application package must be complete
4) Reference Letters
and must be received by April 24, 2009 for the application
Please include a total of 3 reference letters. Letter writers
to be considered. Late or incomplete applications will not
must complete the grid on the enclosed recommendation
be considered
form. *Please photocopy this recommendation form and
Assemble your application package as follows:
distribute one to each letter writer. Letter writers should
1) Application Form
answer the qualitative questions on a separate page and
2) Student Aid Report (SAR) – not the FAFSA
submit both the grid form and the qualitative answers to
3) Three Personal Statements
you in a sealed envelope with the writer’s signature across
4) Reference Forms and Letters (3)
the seal. Letters of reference from family members will not
5) Official Transcript(s)
be accepted.
6) Proof of Cancer Diagnosis
 One form and letter must be from a member of
7) Current photo (emailed by April 24, 2009)
your comprehensive health treatment team. This
8) Quotable (emailed by April 24, 2009)
person must use professional letterhead to answer
the qualitative questions. 9) Deadline
 One form and letter must be from one of your All applications must be complete and received no later
academic subject teachers/professors. than April 24, 2009. Use adequate postage and allow
 One form and letter must be from an adult (over enough time for it to reach the address below. We
21) who is NOT a relative. recommend sending by certified mail to ensure receipt.
Letters must be included with your application materials. Send your application to:
Young Cancer Survivor Scholarship Program
American Cancer Society, California Division, Inc.
1710 Webster Street, Oakland, California 94612
These guidelines are valid only for the 2009-2010 Young Cancer Survivor Scholarship Program
2009 –2010 APPLICATION FORM, page 1 of 2
American Cancer Society, California Division, Inc.
Young Cancer Survivor Scholarship Program
1710 Webster Street  Oakland, California  94612

This form can be photocopied. All sections MUST be completed in order for your application to be considered.
This form by itself is not a complete application package. See the page titled “Scholarship Application Procedures.”
All applications must be received no later than April 24, 2009.
Late or incomplete applications will not be considered

1) Applicant (Please type or print clearly)

M F
Last Name First Name Middle Initial Sex (circle one)
( ) ( )
Home Phone Cell Phone (if available) E-mail

Street Address
California
City State ZIP
- -
Date of Birth Age on April 24, 2009 Social Security Number

____ yes Are you a permanent California ____ yes

Are you a U.S. Citizen? ____ no resident? ____ no

2) School Information
Current School

School Name School District (For Public Schools Only)

( ) ( )
School Phone School Fax (If Available)

School Street Address

City State ZIP

Other Schools
Please list all other secondary (high school) and post secondary (college/university) schools attended.
Dates Enrolled School City/State Grade(s) Attended
-
-
-

Estimated Family Contribution Rating (EFC)

This number can be found on your FAFSA Student Aid Report (SAR).
EFC Rating It should be a numeral from 0 – 999,999.
This form is valid only for the 2009-2010 Young Cancer Survivor Scholarship Program
2009-2010 APPLICATION FORM, page 2 of 2
American Cancer Society, California Division, Inc.
Young Cancer Survivor Scholarship Program

5) Reference Letters (3)

Please include the contact information of the individuals who are writing letters in support of your application. This
section MUST be completed in full with all requested information provided.
Member of Comprehensive Health Treatment Team

Name Title
( ) ( )
Affiliation (hospital, organization or otherwise.) Phone Fax
Academic Teacher

Name Title
( ) ( )
School Phone Fax
Other Adult (NOT a relative)

Name Title
( ) ( )
Affiliation (hospital, organization or otherwise.) Phone Fax

6) Cancer Diagnosis
Provide the following information about your oncologist writing to confirm your cancer diagnosis.

Name Title
( ) ( )
Affiliation (hospital or otherwise.) Phone Fax

7) College or University
Name of California college or university you are attending or plan to attend:
__________________________________________________
Are you currently accepted for admission? Yes ____ No _____
If not, when do you expect to be notified of acceptance? _____________________________________________________
Potential area of study _____________________________________________________________________________________
How did you learn about the Young Cancer Survivor Scholarship Program? _____________________________________
___________________________________________________________________________________________________________

8) Signatures
- -
Applicant’s Signature Date Applicant’s Social Security Number

( )
Parent/Guardian’s Name if applicant is under 18 Daytime Phone of Parent/Guardian

Parent/Guardian’s Signature if Applicant is under 18 Date

9) Declination of use of application materials for marketing

I do not allow the American Cancer Society to use portions of my personal statements, essays, or quotable
from my scholarship program application package for marketing purposes.
(check box only if you wish to keep ALL portions of your application package confidential)

This form is valid only for the 2009-2010 Young Cancer Survivor Scholarship Program
LETTER OF REFERENCE FORM
American Cancer Society, California Division, Inc.
Young Cancer Survivor Scholarship Program
1710 Webster Street · Oakland, California · 94612

Applicants must photocopy this form and provide one to each of the letter writers. All letter writers MUST complete this
form and submit an additional document with answers to the qualitative questions. Letter writers should return both
documents to the applicant in a sealed envelope with the letter writer’s signature across the seal.
These letters should be included in your complete application packet.
Incomplete letters (quantitative and qualitative portion missing) or unsigned letters will not be accepted and will deem
the application ineligible for review.

A. Applicant (To Be Completed by Student)

( )
Last Name First Name Home Phone

This letter of recommendation is from (Please check one.):

 Comprehensive Health Treatment Team Member
 Academic Instructor
 Other Adult

B. Letter Writer (To be completed by letter writer)

Name of Letter Writer Title

Affiliation (organization, school, hospital, or otherwise)

( ) ( )
Phone Fax E-mail

C. Grid (Quantitative portion of Letter of Reference)

Please rate the student on the following criteria by marking an X in the appropriate box, only one box per criterion.
Criteria 1 Weak 2 Average 3 Excellent 4 Outstanding Unable to Evaluate
Academic Motivation
Academic Potential
Creativity
Self Discipline
Leadership
Initiative
Reaction to Setbacks
Analytical Ability
Oral Communication
Classroom Participation
Written Communication
Independence
Problem Solving
Overall Impression of Candidate

D. Qualitative Questions: Please answer the following questions on a separate page. Please include the student’s name
on any separate pages. Please be candid in your answers. Answers must be typed and clearly labeled. The comprehensive
health treatment team member should use letterhead to answer these questions. Please include your answers to these
questions and this complete form in a single envelope with your signature across the seal.
a. For how long and in what capacity have you known the candidate?
b. What is your general impression of the candidate? In your opinion, has the candidate exhibited/demonstrated a
commitment to volunteer service?
c. Based on your knowledge of this person, is the candidate prepared to succeed in a college or university setting? Why?

This form is valid only for the 2009- 2010 Young Cancer Survivor Scholarship Program