EmailMeForm
Name
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Date Time
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MM
/
DD
/
YYYY
Address
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Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Telephone Number
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Email Address
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School or College Attending:
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School Address
*
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
School Email
*
Course of Study (current students):
Number of years completed:
Letter from doctor/nurse or social worker verifying Sickle Cell Disease
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Letter of acceptance from a prospective college, technical school, or graduate school
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Copy of transcript with GPA of 2.5 or more.
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Two (2) letters of recommendation (one from a community representative and one from a school official);
Letter 1
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Letter 2
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An essay (minimum of 500 words) describing your goals and aspirations with applicant’s signature and a recent photo. (All photos and essays are subject to publication in the SCANCA, INC newsletter.)
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