CHS JAMES KREPPNER MEMORIAL
MATURE STUDENT BURSARY PROGRAM /

Purpose of the mature student bursary program

Recent changes in economic realities have made many Canadians seriously look at new careers. While one could once look forward to a lifelong career in one occupation, now several different and quite distinct jobs might be one’s expectation. In addition, many persons with hemophilia or their spouses have had to leave their field of employment because of illness caused by either HIV, hepatitisC (HCV), or the stress simply associated with living in a home that has been affected by the trauma of disease. But these changes often mean that further education is desirable or essential. With that in mind, the CHS offers a mature student bursary in the amount of $5,000 for those students returning to or beginning a course of studies at any post-secondary institution.

Specific criteria for mature student bursary

1. A demonstration of financial need: the applicants must submit a detailed budget showing their sources of income and their projected expenses for a year of study at the institution of their choice. It is expected that the applicants will provide some monies toward their education.

2. Proof of age. The applicant must be at least 30 years of age in order to qualify for the mature student bursary.

3. A statement of intent. The applicant must supply a document (a short essay will do) that details what his or her past employment has been, what the proposed career change will offer, and a personal assessment of how the new career will affect the applicant’s lifestyle.

4. Applicants must provide two (2) letters of reference with their application, none of which may be from a relative. Such letters should attest to the abilities and suitability of the candidate for the Program being applied for as well as act as a character reference for the candidate. Suitable referees might include a teacher, employer, colleague, clergyman or a community representative.

5. The applicant must also provide, with the application, the signed Proof of Eligibility Form from his/her physician or some medical authority confirming his/her medical status (or that of his/her spouse or parent) regarding eligibility to this program.

Application Process

Applicants should forward a paper copy of the completed application form along with supporting documents to: Canadian Hemophilia Society

301-666 Sherbrooke Street West

Montreal, Quebec H3A 1E7

Applications must be postmarked no later than April 30.

CHS JAMES KREPPNER MEMORIAL
MATURE STUDENT BURSARY PROGRAM
APPLICATION FORM /

Part A: Personal information

Name: First name:

Date of birth:

Address:

City: Province: Postal code:

Telephone:

Home Business

E-mail address:

Mailing address:

(if different from above)

City: Province:

Postal code:

CHS JAMES KREPPNER MEMORIAL
MATURE STUDENT BURSARY PROGRAM /

Name of applicant:

Part B: Name of proposed post-secondary institution

Name:

Address:

City: Province: Postal code:

Program of studies:

Part C: Names of referees

Letters of reference can either be included with the application in individually sealed envelopes or be directly submitted to the Canadian Hemophilia Society by the referees.

1. Name:

Address:

City: Province: Postal code:

2. Name:

Address:

City: Province: Postal code:

CHS JAMES KREPPNER MEMORIAL
SCHOLARSHIP AND BURSARY PROGRAM /

Name of applicant:

Part D: Proof of Eligibility

The program is open to Canadians with hemophilia (factor VIII or IX) or another inherited bleeding disorder (such as von Willebrand disease, a rare factor deficiency or platelet function disorder), carriers, and those who contracted HIV through a blood transfusion. Spouses and children of the above mentioned people may also apply.

Please include a copy of this Proof of Eligibility Form, signed by your physician or some medical authority, confirming your eligibility to this program.

I confirm that this person meets the above criteria:

I confirm that this person’s parent or spouse meets the above criteria:

Name of physician or medical authority:

Institution or location of practice:

Signature:

Date:

Note to Physicians/Nurses: Please do not attach any patient consult reports or lab results. CHS requires only the information indicated on this form. Thank you for your time.

CHS JAMES KREPPNER MEMORIAL
MATURE STUDENT BURSARY PROGRAM /

Name of applicant:

Part E: Name of the essay:

For mature student bursary applicants

Applicants must supply a statement of intent (a 500 word essay will do) that details what his or her past employment has been, what the proposed career change will offer, and a personal assessment of how the new career will affect the applicant’s lifestyle.

Part F: Budget

In designing your budget make it inclusive for a regular academic year (i.e., eight months), so that, for example, your rent total is for the full period (e.g., $300 X 8 = $2,400). You will probably have to estimate book costs; science courses are more expensive, generally.

Income Possible Expenses

Employment: $ Tuition: $

Other sources (Please specify): Books: $

$ Housing: $

$ Food: $

Child care: $

Transportation: $

Utilities: $

Leasure: $

Other: $

TOTAL: $ TOTAL: $

CHS JAMES KREPPNER MEMORIAL
MATURE STUDENT BURSARY PROGRAM /

Name of applicant:

The applicant’s checklist

Application:

Proof of age:

Signed Proof of Eligibility Form:

Two referees:

Budget:

Essay:

In the event that I should be the recipient of a scholarship or bursary under the James Kreppner Memorial Scholarship or Bursary Program, I agree that my biography and photo can be used on the CHS website, in the CHS newsmagazine, Hemophilia Today, and in the CHS annual gratitude report, Thanks to You.

Signature Date

The CHS James Kreppner Memorial Scholarship and Bursary Program supported by

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