A.

Richard Grossman Scholarship Fund

Applicants must meet the following criteria to be eligible:
1. A burn survivor. 2. Currently a high school senior, earned a GED, or currently enrolled in a college or university. 3. Demonstrated academic achievement as shown by grades and scores on standardized tests. 4. Accepted to an accredited college or university. 5. Require financial assistance. Please provide copy of FAFSA Application. http://www.fafsa.ed.gov/fotw1112/pdf/PdfFafsa11-12.pdf

Please attach the following items to your application:

For High School Students: 1. An official high school transcript that includes credits and GPA or official copy of GED. 2. Acceptance letter from college or university. For College Students: 1. An official transcript for current students that includes credits and GPA (if applicable). 2. A copy of invoice from your college or university. For ALL Students: 3. One letter of reference from non-school staff and non-family members. (Use current employer if you work.) 4. One letter of reference from school staff; counselor, administrator or teacher/professor. An essay answering at least one of the following questions: 1. On what basis do you think that you are a deserving scholarship recipient? (Can include life experience, community service you have done in the past, academic strengths, and/or extracurricular activities.) 2. How will your college/university degree contribute to your life and your future life goals after you graduate? 3. How has your burn injury influenced and impacted your life and the person that you are today? 4. Other than family members, who is one individual that you consider your hero, heroine, or role model? What characteristics, achievements, etc. do you admire about the individual and how do they influence your life?

All elements of the application must be completed by the deadline to be considered. DEADLINE: Please return in one package postmarked by June 1, 2012. Recipients will be notified and awarded by June 15, 2012. ****Scholarships are $2,500 and are limited based on available funding**** Mail Application to: Circle of Care Burn Foundation, 16255 Ventura Blvd., Suite 707 Encino, CA 91436

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Circle of Care Burn Foundation 16255 Ventura Blvd., Suite 707 Encino, CA 91436

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A. Richard Grossman Scholarship Fund Biographical Information

(Please print or type CLEARLY and fill out COMPLETELY). Name Date of Birth Social Security # Address City Email Address Phone: Home (area code) Work (area code) Parent/Guardians Names Occupation Phone: Home (area code) Work (area code) Cell (area code) State Zip

Cell Phone (area code) __________________________________________________ Familys Annual Income Name of burn center and city you were treated? __________________________________ Name of your primary burn doctor? __________________________________________ In the event you are awarded a scholarship, may we contact the facility and doctor on your behalf to let them know of the award Yes________ No_______ What school do you currently attend? (Give full name, address and phone number)

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Circle of Care Burn Foundation 16255 Ventura Blvd., Suite 707 Encino, CA 91436

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**Please include a headshot photo (high resolution, 2-3MB, JPEG file preferred) of yourself on a CD OR e-mail a headshot photo of yourself to: info@circleofcareburnfoundation.org. Applications without photos will be DISQUALIFIED.**

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Circle of Care Burn Foundation 16255 Ventura Blvd., Suite 707 Encino, CA 91436

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A. Richard Grossman Scholarship Fund

Please provide an itemized statement of financial need for the 2012-2013 academic year and any sources of financial assistance you currently have or anticipate receiving: Costs: Tuition and Fees: Room and Board: Books: TOTAL COSTS: Financial Aid: Description Amount Applied For Amount Granted 1. 2. 3. 4. 5. Other circumstances contributing to your financial need at this time.

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Circle of Care Burn Foundation 16255 Ventura Blvd., Suite 707 Encino, CA 91436

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