2018 Scholarship Application

2018 Vincent J. Vittore Memorial Scholarship Application

The Vincent J. Vittore Memorial Scholarship was founded by the BTB Foundation to honor the enthusiasm, humor and strength that Vince displayed during his life and for his love for family, friends and great journalism.

Award:

Two $5,000 scholarships for academic year 2018-2019

Eligibility:

US Citizen between the ages of 17 and 30
Reside in the Chicago metropolitan area (Cook, DuPage, Grundy, Kane, Kankakee, Kendall, Lake, McHenry or Will county)
Applicants must be a cancer patient, cancer survivor or has an immediate family member that is a cancer patient, cancer survivor or has passed away due to cancer. “Immediate Family” is defined as Mother, Father, Brother or Sister.
Applicants must plan to enroll as a full-time student (minimum 12 semester hours) in pursuit of a certificate or undergraduate degree at an accredited 2 or 4 year College/University for the 2018-2019 academic year. Special consideration will be given to those pursuing a journalism degree.

Key Dates:

Applications Accepted - January 31, 2018 through March 31, 2018
Awards Decided - May 1, 2018
Formal Announcement - May 18, 2018 at BTB Charity Golf Outing

The information entered on this scholarship application will be reviewed by the BTB Foundation and the Vince J. Vittore Scholarship Fund Committee. All information is strictly confidential and is for the BTB Foundation use only.

Please complete all required sections and submit all required application materials. If you have any questions or if you need any assistance while completing this scholarship application, please contact Bill Latourette at 847.830.1907 or email us at scholarship@btbfoundation.org.

Applicant Information

* Indicates required field

Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone number (home) *

Phone number (cell) *

Best means of communication *

home phone cell phone/text email

Date of birth *

Applicants gender *

US Citizen? *

Yes No

Family Member Diagnosed with Cancer *

First

Last

Relationship *

Guardian Information (if applicant is under the age of 18)

Name *

First

Last

Email *

Relationship to applicant *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Phone number (home) *

Phone number (cell) *

Best means of communication *

home phone cell phone/text email

Applicant Academic Information

High School or College/University Currently Attending *

Anticipated College/University for 2018-2019 academic year *

College/University Address *

Line 1

Line 2

City

State

Zip Code

Country

GPA from last official transcript (High School or College/University) *

ACT Score *

SAT Score *

Honors and/or Academic Awards *

Anticipated Major(s) *

Expected Date of College Graduation *

Amount of currently awarded scholarships for the 2018-2019 academic year *

Interests/Volunteer Activities *

How did you learn about this scholarship? *

Medical Information for Cancer Patient

You understand that Congress passed a law entitled the Health Insurance Portability and Accountability Act (HIPAA) that limits use, disclosure or release of my individually identifiable health information, as HIPAA and the supporting Regulations define that phrase. I am signing this authorization because it is crucial that my health care providers release, or disclose my protected medical information to BTB Foundation and its directors and members, for the sole purpose of obtaining a statement of diagnosis from my treating physician for the purposes of this application for financial assistance.

With regard to information disclosed under this authorization, you waive any right of privacy that you may have under the authority of the Health Insurance Portability and Accountability Act of 1996, Public Law 104-191 (HIPAA), any amendment or successor to that Act, or any similar state or federal act, rule, or regulation. In addition, you release any covered entity that acts in reliance on this authorization from any liability that may accrue from the use or disclosure of your individually identifiable health information in reliance upon this authorization and for any actions taken by BTB Foundation.

Primary cancer type *

Cancer stage (if applicable) *

Date of diagnosis *

Is this a new cancer diagnosis? *

yes no

Please explain *

Are you currently receiving cancer treatment? *

yes no

Date of last treatment *

Please describe the treatments you have received in the past 12 months *

Please describe any treatments/costs not covered by health insurance *

Do you or the family member diagnosed with cancer (if not deceased) have health insurance? *

yes, the applicant has health insurance no, the applicant does not have health insurance

If you or the family member (if not deceased) is covered by health insurance, does the insurance cover prescription drugs? *

yes, the applicant's insurance covers prescription drugs no, the applicants insurance does not cover prescription drugs n/a, the applicant does not have insurance

Statement of Diagnosis

A statement of diagnosis provided by your physician is required before the BTB Foundation can complete the review of your application. Please submit the Statement of Diagnosis to the BTB Foundation by:

Email to assistance@btbfoundation.org
Fax # 224-267-0788
Mail to: BTB Foundation, 820 W. Dresser Drive, Mt. Prospect IL 60056

Note: Under the Health Insurance Portability and Accountability Act (HIPAA) you are required to provide an authorization and release for the BTB Foundation to obtain the statement of diagnosis. Your completing and submitting this application provides the BTB Foundation with the HIPAA Authorization and Release requirements.

Financial Information

Combined household gross income of family applying for assistance *

Is the applicant employed *

Yes No

If the applicant is a minor, are the applicant's guardian's currently employed? *

yes, guardian's are employed one guardian does not work so that they can care for the applicant both guardian's do not work so that they can care for the applicant

Please describe the applicant's household sources of income (examples include wages, family assistance, social security, disability, public aid, pension and unemployment) *

Additional Information

Please provide any additional information that you would like the BTB Foundation to know/consider while reviewing your application *

Sharing names and email addresses of family and friends with the BTB Foundation

Your family and friends participation in the BTB outings are critical to our success. The BTB Foundation will invite your friends and family to BTB fundraising events. Any names and/or email addresses you provide will only be used by the BTB Foundation and will not be shared with any other party *

Yes, I am willing to share names and addresses of family and friends with the BTB Foundation No, I am not willing to share names and email addresses ith the BTB Foundation

Application Materials

In order for the BTB Foundation to review your application for the Vincent J. Vittore Memorial Scholarship, the following must be completed and submitted before the March 31, 2018 deadline:

Video (2-3 minutes)

What was the biggest adjustment in your life since you/your family members battle with cancer began/ended? What do you prize more now than before this experience? What advice would you give to someone who has just been diagnosed or has/had a family member diagnosed?

Essay (Minimum of 500 words/Maximum 800 words)

Describe how your academic motivation and interests, professional and volunteer experience and career objectives were altered by cancer.
What have you learned from this experience and how might you help others because of it?

High School or College/University transcript:

Scanned copy of the latest official transcript showing GPA

College/University Acceptance Letter:

Scanned copy of the acceptance letter for academic year 2018-2019 from the College/University you plan to attend

Statement of Diagnosis:

A statement of diagnosis provided by the primary cancer physician to certify that the family member or applicant has/had cancer, or a copy of the Certificate of Death stating cancer as the cause of death, if applicable.

Letters of Recommendation :

Arrange for two letters of recommendation to be sent to the BTB Foundation on your behalf. The letters must be from an unrelated adult who has been involved with you in some significant way inside and/or outside of school. The writer should describe how they have come to know you, what they see as your major strengths and limitations and why the BTB Foundation should consider your scholarship application.

Application materials can be sent via the following methods:

Email to assistance@btbfoundation.org
Fax # 224-267-0788
Mail to: BTB Foundation, 820 W. Dresser Drive, Mt. Prospect IL 60056

Award Acceptance

Award recipients must provide the following for award acceptance:

Social Security Number

Your Social Security Number will only be used to complete a background check.
In order to protect you and the BTB Foundation from fraud, we require that a criminal background investigation be administered. This does not include a credit report or a credit history. The criminal background investigation is at no cost to you and is the responsibility of the BTB Foundation. All information obtained, if any, during the criminal background investigation will be provided to you. The BTB Foundation will hold the information confidential and will not release the information to any third parties. We are required to obtain authorization from you to complete this criminal background investigation.

Proof of full-time student enrollment at College/University

Scholarship awards will be paid directly to the College/University in two increments of $2,500.
Scholarship recipients must provide class schedule showing enrollment for full time studies (minimum of 12 credit hours) before each semester for the 2018-2019 academic year.
College/University will be instructed to return any scholarship funds to the BTB Foundation in the event tuition funds are refunded to the recipient.

Proof of Minimum GPA

Scholarship recipients must maintain a minimum of a C+ average (2.3 GPA on a scale of 4.0).
College/University transcripts must be provided after the first semester proving GPA before the second scholarship increment is disbursed.

Submitting a Completed Application

In order for the BTB Foundation to review your application, the following must be completed and submitted before the 3/31/18 deadline:

Electronically sign this application including social security number of applicant or guardian
Compete all required fields and click on the 'submit' button (below)
The BTB Foundation must receive a Statement of Diagnosis from your doctor
Provide two to three reference letters from family and/or friends describing why the BTB Foundation should consider your request.

The Statement of Diagnosis and the reference letters can be sent to the BTB Foundation via:

Email to assistance@btbfoundation.org
Fax # 224-267-0788
Mail to: BTB Foundation, 820 Dresser Drive, Mt. Prospect, IL 60056

Background Check

In order to protect you and the BTB Foundation from fraud, we require that a criminal background investigation be administered. This does not include a credit report or a credit history. The criminal background investigation is at no cost to you and is the responsibility of the BTB Foundation. All information obtained, if any, during the criminal background investigation will be provided to you. BTB Foundation will hold the information confidential and will not release the information to any third parties. We are required to obtain authorization from you to complete this criminal background investigation.

By electronically signing this application below, you are hereby consenting/authorizing the BTB Foundation to complete a background check of the applicant / applicant's guardian.

Please call Bill Latourette @ (847) 830-1907 with your SS# (or SS# for guardian(s) if applicable). Note: your SS# will only be used to obtain the background check.

Electronic Signature

Applicant Name (guardian name if applicant is a minor) *

I confirm that I am the applicant/applicant's legal guardian and I confirm that by entering my name in the applicant name field I have electronically signed this application *

yes, I confirm my electronic signature no, I am not the applicant/applicant's legal guardian and I have not electronically signed this application

Submit

Vincent J. Vittore memorial Scholarship Fund - 2018 Application

2018 Vincent J. Vittore Memorial Scholarship Application

Applicant Information

Guardian Information (if applicant is under the age of 18)

Applicant Academic Information

﻿Medical Information﻿ for Cancer Patient

Statement of Diagnosis

Financial Information

Additional Information

Sharing names and email addresses of family and friends with the BTB Foundation

Application Materials

Award Acceptance

Submitting a Completed Application

Background Check

Electronic Signature

Vincent J. Vittore
memorial Scholarship Fund - 2018 Application

Medical Information for Cancer Patient