2014 2015 Benjamin R. Chirls Scholarship

2014 – 2015 BENJAMIN R. CHIRLS SCHOLARSHIP

NJ SHARING NETWORK FOUNDATION

The NJ Sharing Network Foundation is pleased to announce the availability of one Benjamin R. Chirls Scholarship in the amount of $4,000 ($2,000 per semester) for the 2014-2015 academic year. The scholarship recipient must be a donor family member, living donor, transplant recipient, waiting for a transplant, or awareness advocate.

NJ Sharing Network Foundation supports the work of NJ Sharing Network to increase the number of lives saved through education, research and public awareness about the life-saving benefits of transplantation. The scholarship is awarded in honor of those who gave, to pay tribute to those who received, to offer hope to those who continue to wait, and to remember the lives lost while waiting… for the gift of life.

Ben Chirls, a kidney recipient, was a strong advocate for organ, eye and tissue donation. Ben worked tirelessly for many years, ignoring physical limitations and disabilities to bring the message of donation to individuals throughout NJ as a volunteer for New Jersey Organ and Tissue Sharing Network. As Treasurer of the New Jersey Coalition on Donation he donated his expertise as a retired accountant. We are proud to award this scholarship in his name.

Eligibility Requirements:

Student must be a New Jersey resident
Student must be a full time high school senior, college, technical, vocational school student or current full time student at any other accredited school of higher education
Student must be a donor family member, living donor, transplant recipient, waiting for a transplant, or awareness advocate
Student must be in top 50% of class
Employees of NJSN or the NJSN Foundation, their spouse and/or children are not eligible for scholarship consideration
Board Members of NJSN and the NJSN Foundation, their spouse and/or children are not eligible for scholarship consideration

Application Requirement Checklist:

☐ Three letters of Recommendation

Please ask that your involvement in donor awareness activities be highlighted; a letter from a supervisor of that organization would be helpful.

☐ Current Transcript

Be sure to include rank and CEEB scores

☐ Essay about organ and/or tissue donation

How organ and tissue donation has impacted your life, knowledge of organ and tissue donation, active participation in awareness events, etc.

Hint: Organ and tissue donation awareness involves educating the general public about the importance of donation. You should elaborate on your activities to promote organ, tissue and eye donation as
donor awareness advocacy is the major factor in determining the scholarship award.

☐ Submission

After completing this application electronically, please print and mail to the address below with all requested application requirements and paperwork:

NJ Sharing Network Foundation, Attn: M. Barlow, 691 Central Avenue, New Providence, NJ 07974

PLEASE NOTE:

All the above application requirements must be met in full.
All paperwork must be submitted in one single packet.

Applications which do not meet these requirements will be considered incomplete and applicants will be ineligible.

DEADLINE – COMPLETE APPLICATION MUST BE POSTMARKED BY FRIDAY, MAY 24, 2014

Funding Requirements: The Awardee of this scholarship will receive the scholarship funds in two payments; one in October and one in April. The award will be paid directly to the school. Receipt of the second half of the award will be contingent upon submission of a brief report (1 typed page) describing recent achievements and activities, which will be due in February. A school transcript will be required at that time. A minimum of a C average, or its equivalent, will be required for receipt of the second half of the award.

BENJAMIN R. CHIRLS SCHOLARSHIP

2014– 2015 APPLICATION

Personal Data:

Name:Last, First, Middle

Address: Street

City, State, Zip Code

Phone:(Area Code) Phone NumberE-Mail Address

Birth Date:MM/DD/YY

Local Newspaper:Name of Newspaper

Address of Newspaper: : Street

City, State, Zip Code

Transplant/Donor Awareness/Affiliation:

Check all applicable

Self Family Member

Living DonorChoose an item Choose an item

Donor Family MemberChoose an item Choose an item

RecipientChoose an item Choose an item

Waiting for a TransplantChoose an item Choose an item

Donor Awareness AdvocateChoose an item Choose an item

Educational Data:

Name of High School: Name of High School From: Date To: Date

Graduation: MM/DD/YY Current GPA: #### Midyear Rank: ###

Name of College Name of College From: Date To: Date

Graduation: MM/DD/YY Current GPA: #### Midyear Rank: ###

School Counselor: Counselor’s Name Guidance Phone: (###) ###-####

College you plan to attend or colleges to which you have been accepted:

Name of CollegeName of College

Work experience:

Name of EmployerFrom: Date To: Date

Name of Employer From: Date To: Date

Organ donor awareness volunteer activities:

Name of Activity Name of Activity

Family Information:

Mother/Guardian: Name Occupation: Name

Contact information: Daytime phone: (###) ###-#### Evening Phone: (###) ###-####

Father/Guardian: Name Occupation Name

Contact Information: Daytime phone: (###) ###-#### Evening Phone: (###) ###-####

DEADLINE – COMPLETE APPLICATION MUST BE POSTMARKED BY FRIDAY, MAY 24, 2014

I hereby authorize and give consent to be contacted by NJ Sharing Network or any of its partners regarding my own personal story as a recipient, donor family member or advocate.

APPLICANT’S SIGNATURE ______DATE ______

I will be available to attend the reception on July 10th, 2014 announcing the successful scholarship recipient if I am selected to receive this scholarship:

____ YES____NO

MAIL COMPLETED APPLICATION TO:

NJ Sharing Network Foundation
Attn: M. Barlow

691 Central Avenue

New Providence, NJ 07974

FAXES WILL NOT BE ACCEPTED.

*Please keep a copy of the completed application for your records.

FOR YOUR INFORMATION:

Notification to Successful Applicant – July 2014

The decision of the Scholarship Committee is final.

Payments to the college or university will be made in 2 installments. Checks will be made payable directly to the institution you attend. Please notify the NJ Sharing Network Foundation immediately if there is a change in your academic status.

****Questions: Charlie Kistinger ****

DEADLINE – COMPLETE APPLICATION MUST BE POSTMARKED BY FRIDAY, MAY 24, 2014

*This is a firm deadline and will not be extended.

Deadline – Must be postmarked by Friday, May 24, 2014

NJ Sharing Network Foundation

691 Central Avenue

New Providence, NJ 07974