| *Date of Birth: |
|
| *First Name: |
|
| *Family Name: |
|
| *Address: |
|
| Â |
|
| *City/Town: |
|
| *Province: |
|
| *Postal Code: |
|
| *Home Phone Number: |
|
| Cell Phone Number: |
|
| *Email Address: |
|
| *Type of childhood cancer: |
|
| *Are you currently being treated for cancer?
Yes
No |
| *Name of High School you will be graduating from: |
| Â |
|
| Name of college / university you hope to enter or in which you are currently enrolled: |
| Â |
|
| City: |
|
| Name of program you will enroll: |
| Â |
|
| Year: |
|
| Â |
 |
| If you are currently accepted into the program, please fax your acceptance letter to us at 416-489-9812. |
| Â |
 |
How did you hear about Scholarship Program:
Website Support Group/ Hospital
Newsletter
Other organization
Other please specify
|
| Â |
 |
| Â |
|
