National Kidney Foundation of Maine

2008 Scholarship Application

1.) Name: ________________________________________________ Age: __________

Address: _______________________________________City: ____________________

State: __________ Zip: __________ Home Phone: ____________________

Work Phone: ____________________ Cell Phone: ____________________

Circle which of the following applies to you:

Nephrology Patient Nephrology Patient Dependent

Dialysis Patient - Unit name: ________________________________

Dialysis Patient Dependent

Kidney Transplant Recipient Kidney Transplant Recipient Dependent

Tissue/Organ Recipient ________________________________

Please specify what you received

Tissue/Organ Recipient Dependent

Tissue/Organ Donor ________________________________

Please specify what you gave

Tissue/Organ Donor Dependent

2.) Name of University, College or School you will be attending:

________________________________________________________________________

Address: _______________________________________City: ____________________

State: __________ Zip: __________ Phone: ____________________

3.) Verification of enrollment / acceptance to school FOR FALL 2008

(Please provide name and telephone number of admission officer along with copy of 1^st semester

tuition bill)

Admission contact person: __________________________________________________

Address: _______________________________________City: ____________________

State: __________ Zip: __________ Phone: ____________________

~ If electing to enroll in course(s) that are non-degree/non major course(s), please list course(s) and all anticipated costs here, and then explain your objectives in the goal description area found at the end of the application.

Major: ___________________________________

Length of Program: ____________________ Date Accepted: ____________________

Semester/ Quarter Enrollment will begin: _______________________________

Please include letter of acceptance - THIS IS MANDATORY

4.) Annual Education Expenses for STUDENT ONLY:

Tuition:_____________

Room & Board:_____________ OR Commuting Costs: _____________

Books:_____________

TOTAL COSTS: _____________

5.) Total household income before deductions on 2007 Federal Income Tax Return

(Line 34- 1040 form, line 21- 1040A form): __________________________

(If married and filed separately, please list both incomes, if you are claimed as a dependent on someone else’s tax return, provide information from that individual(s) return)

Number of dependents (line 6d- IRS form 1040): _______________

Number of dependents that will be attending University or College _______________

6.) Do you have any other sources of income or financial aid?

	Source	Amount
Scholarships
Government Loans
Grants/Work study
Other

7.) Please provide a copy of your financial aid award letter

8.) Please submit a typed essay on the following topics, and then sign at the bottom.

- Your educational goals - How this has impacted your life

This information provided herein is, to the best of my knowledge, complete & accurate.

___________________________________________

Signature of ApplicantDate

___________________________________________

Parent/Guardian (if under 18) Date

If chosen to receive an award, do you grant permission to the

National Kidney Foundation of Maine to use your name in our newsletter?Yes oNo o

(Please note: THIS DOES NOT EFFECT COMMITTEE DECISIONS)

Deadline

August 1, 2008

Please return to:

NKFM Scholarship Committee * 470 Forest Ave. Suite 302 * Portland, Maine04101 *

Please call with any questions or concerns:

Phone: (207) 772-7270Fax: (207) 772-4202