Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. - Step 1 of 8ELIGIBILITY: All applicants must be U.S. residents. All applicants must submit a transcript to complete the application prior to the submission deadline. All applicants must complete an essay at time of completing this online application. All applicants must provide the name, title & email address of their formal reference; which must be a guidance Counselor, Principal, Professor/Teacher or President/Dean of College at the time of submission. In addition, all applicant's have the sole responsibility of providing the Reference & Rating form to their referral POCs, as well as following up on their submission of reference by the March 1st deadline. A. Excellence in Academics and Community Service Award Must be a brain tumor patient/survivor or closely related to someone diagnosed with a brain tumor. Relationships are limited to spouse, biological children, biological parents, biological siblings. Must be entering or currently enrolled in an advanced educational program at a college, university, vocational school or other setting within the fifty United States or District of Columbia. Must have at least a GPA of 3.0/4.0 or a 4.0/5.0. l Rank in top half of class and have at least an SAT score of 1000 or an ACT of 21. Demonstrate strong leadership and service in their community. B. Excellence in Science and Medicine Award Must be entering or currently enrolled in an advanced educational program within the health sciences (including biology, chemistry, nursing, etc.) with the intent to enter the field of oncology or neurology (including neuroscience, neurosurgery, and neuropathology) at a college or four-year university within the fifty United States or District of Columbia. Must have a GPA of 3.0/4.0 or 4.0/5.0. l Must have three (3) years of science courses with a minimum grade letter of B in each course. Rank in the top half of class and have at least an SAT score of 1000 or an ACT of 21. C. The Karen Lewis CTU Excellence in Science Award Created in honor of Chicago Teachers Union (CTU) President Karen Lewis. Must be a current student or graduate of a Chicago Public School (CPS). Must be entering or currently enrolled in an advanced educational program within the health sciences (including biology, chemistry, nursing, etc.); pursuing a technical certification, associate or bachelor level degree; with an emphasis in science and/or screening and research in the areas of oncology or neurology (including neuroscience, neurosurgery, and neuropathology) at a college or four year university within the fifty United States or District of Columbia. Must have a GPA of 3.0/4.0 or 4.0/5.0. Must have three (3) years of science courses with a minimum grade letter of B in each course. Rank in the top half of class and have at least an SAT score of 1000 or an ACT of 21. To get started, replace this text with your own. Please select the scholarships above in which you are eligible to apply. *Excellence in Academics & Community Service AwardExcellence in Science & Medicine AwardThe Karen Lewis CTU Excellence in Science AwardA and CB and CSelect applicant relationship to the patient/survivor and complete the diagnosis information.I am the patientI am the child of the patientI am the sibling of patientPatient Tumor TypeDate of Patient DiagnosisDiagnosing Facility Name *Facility LocationAddress Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeI have read and understand the eligibility requirements. *Yes, I haveIf selected, you will be asked for documentation to support the data you provide. Likewise, all correspondence and award agreements will be generated from the personal information submitted below. So, please use proper spelling, capitalization and punctuation.NextName *FirstLastBirthdate: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone *Email *Home Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeOptional Informations: Information regarding gender, ethnic origin and race are optional. The information is requested for post-scholarship report generation only and in no way affects your selection for college scholarship awards. However, providing this information may increase your opportunities for scholarships where donors have asked that priority consideration be given to students meeting certain demographic criteria (such as minority status, parent's place of employment, area of study, etc.) GenderMaleFemaleUS CitizenYesNoEthnic OriginHispanicNon-HispanicNot IndicatedRace? (Choose one or more)WhiteBlack or African AmericanAsianAmerican Indian or Alaskan NativeHawaiian or Other Pacific IslanderNon-Resident AlienPreviousNextName of High School *School Location *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCurrent GPA *Cumulative GPA *Class RankYear of High School Graduation or GED *High School ActivitiesPlease list all high school activities such as; offices held or other honors, community activities, volunteer work with name of organization & amount of time spent in days/months/years of service. Section DividerName of College/University *Address *Address Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateCumulative GPA *Area of Study *College/University Activities *Please list all college/university activities such as; offices held or other honors, community activities, volunteer work with name of organization & amount of time spent in days/months/years of service.PreviousNextACTSATAll scholarship applicants reporting an ACT/SAT score will be asked to provide official verification. PreviousNextCurrent GPAParagraph TextPreviousNext Tumor Gender Layout May E. Smith (M.O.M.) Foundation, Inc./Memories of Mary has taken positive stands on important issues affecting the community and takes pride in working for the betterment of all people. Select a current issue important to you and discuss how your education will allow you to make an impact. Essay *PreviousNextThe Reference & Rating form MUST be completed by a Guidance Counselor, Principal, Professor/Teacher or President/Dean of College utilizing the link embedded here that you MUST provide to them via a copy & paste of the form link. The reference should match the information you provide in this section. Name of Reference *FirstLastTitle of Reference *Organization/School of ReferenceEmail of Reference *PreviousNextBy signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please retain for your records as verification of your application. Checkboxes *I agreeYES, I am sending a copy of my school transcript to Mary E. Smith Foundation, Inc. 2035 S. State St #16-703 Chicago, IL. 60616. Fax (708) 342-0800. Email information@maryesmithfoundation.org. Furthermore, If chosen as a recipient, I will provide an official copy to the charity & participate in recipient acknowledgement activities (annual brain tumor walk & scholarship event).PreviousSubmit