Application Survey

Question Title

1. Information

Name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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2. Age

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3. Date of Birth

Date / Time

Date

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4. Gender

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5. Ethnicity

White

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Other

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6. GPA

3.0-3.2

3.3-3.5

3.6-3.8

3.9-4.0

4.0+

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7. Are you enrolled in AP or Honors Classes? (Required.)

Yes

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8. What type of CHD do you have? (Required.)

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9. Name of Institution that treats your CHD? (Required.)

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10. Have you had surgery for your CHD? (Required.)

Yes

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11. If you answered yes to #10, please list all CHD surgeries. (Required.)

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12. Have you had any non-CHD surgeries? (Required.)

Yes

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13. If you answered yes to #12, please list surgeries. (Required.)

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14. Do you have any siblings? (Required.)

Yes

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15. If yes, do any of your siblings have a serious medical condition?

Yes

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16. What college/university/trade school do you hope to attend or have been accepted to? (Required.)

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17. What degree or certificate do you hope to achieve?

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18. What activities, clubs or sports were/ are you involved in? (Required.)

Sports

Music

Performing Arts

Arts

Community Service

Activism

Academic Clubs

Volunteer

Job

Internship

Apprenticeship

Other

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19. Describe the kinds of obstacles you have had to overcome due to having a CHD and the impact those might have on your educational and life goals for the future. (Required.)

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20. As a patient with a CHD, if you could make any change to the system of care to improve the patient experience, what would it be? (ie: better education, more streamlined care, more centralized care...) (Required.)

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21. Please list one (1) reference (name, email & phone number) (Required.)

Question Title

22. Do you authorize the Heart Warrior Achievement Scholarship to use your information for CHD awareness or marketing?

Name Only

Name & Photo

Photo Only

Name, Photo, & Essay Content

Essay Only

None of the Above

Application

Heart Warrior Achievement Scholarship Application

Question Title

* 1. Information

Question Title

* 2. Age

Question Title

* 3. Date of Birth

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* 4. Gender

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* 5. Ethnicity

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* 6. GPA

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* 7. Are you enrolled in AP or Honors Classes? (Required.)

Question Title

* 8. What type of CHD do you have? (Required.)

Question Title

* 9. Name of Institution that treats your CHD? (Required.)

Question Title

* 10. Have you had surgery for your CHD? (Required.)

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* 11. If you answered yes to #10, please list all CHD surgeries. (Required.)

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* 12. Have you had any non-CHD surgeries? (Required.)

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* 13. If you answered yes to #12, please list surgeries. (Required.)

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* 14. Do you have any siblings? (Required.)

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* 15. If yes, do any of your siblings have a serious medical condition?

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* 16. What college/university/trade school do you hope to attend or have been accepted to? (Required.)

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* 17. What degree or certificate do you hope to achieve?

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* 18. What activities, clubs or sports were/ are you involved in? (Required.)

Question Title

* 19. Describe the kinds of obstacles you have had to overcome due to having a CHD and the impact those might have on your educational and life goals for the future. (Required.)

Question Title

* 20. As a patient with a CHD, if you could make any change to the system of care to improve the patient experience, what would it be? (ie: better education, more streamlined care, more centralized care...) (Required.)

Question Title

* 21. Please list one (1) reference (name, email & phone number) (Required.)

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* 22. Do you authorize the Heart Warrior Achievement Scholarship to use your information for CHD awareness or marketing?

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* 23. Transcript or Academic Record

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* 24. Practioner's letter confirming your CHD diagnosis

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* 25. Recommendation Letter

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* 26. Your Photo

1. Information

2. Age

3. Date of Birth

4. Gender

5. Ethnicity

6. GPA

7. Are you enrolled in AP or Honors Classes? (Required.)

8. What type of CHD do you have? (Required.)

9. Name of Institution that treats your CHD? (Required.)

10. Have you had surgery for your CHD? (Required.)

11. If you answered yes to #10, please list all CHD surgeries. (Required.)

12. Have you had any non-CHD surgeries? (Required.)

13. If you answered yes to #12, please list surgeries. (Required.)

14. Do you have any siblings? (Required.)

15. If yes, do any of your siblings have a serious medical condition?

16. What college/university/trade school do you hope to attend or have been accepted to? (Required.)

17. What degree or certificate do you hope to achieve?

18. What activities, clubs or sports were/ are you involved in? (Required.)

19. Describe the kinds of obstacles you have had to overcome due to having a CHD and the impact those might have on your educational and life goals for the future. (Required.)

20. As a patient with a CHD, if you could make any change to the system of care to improve the patient experience, what would it be? (ie: better education, more streamlined care, more centralized care...) (Required.)

21. Please list one (1) reference (name, email & phone number) (Required.)

22. Do you authorize the Heart Warrior Achievement Scholarship to use your information for CHD awareness or marketing?

23. Transcript or Academic Record

24. Practioner's letter confirming your CHD diagnosis

25. Recommendation Letter

26. Your Photo