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Application

Heart Warrior Achievement Scholarship Application

Please fill out the form and attach required documents
1.Information
2.Age
3.Date of Birth
Date / Time
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 degree or certificate do you hope to achieve?
17.What activities, clubs or sports were/ are you involved in?(Required.)
18.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.)
19.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.)
20.Please list one (1) reference (name, email & phone number)(Required.)
21.Do you authorize the Heart Warrior Achievement Scholarship to use your information for CHD awareness or marketing?
22.Transcript or Academic Record
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23.Practioner's letter confirming your CHD diagnosis
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24.Recommendation Letter
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25.Your Photo
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