The FAMOHIO Les Gutter Memorial Scholarship is open to any person attending FAMOHIO diagnosed with Hemophilia, Von Willebrand Disease or other bleeding disorders seeking to further their education at a university or technical college. There is the minimum of one2,000.00 scholarship awarded per year. Additional scholarships may be awarded as indicated.

Each application must include the following documents, sent together in one package:

  • Completed application
  • Essay
  • Proof of Enrollment or Letter of Acceptance to a College or Technical School
  • Letter from Hemophilia Treatment Center or Physician documenting a bleeding disorder

diagnosis

  • Reference letter from a teacher, community member or employer

Application and supporting documents must be POSTMARKED by September 18, 2017. Decision by the

scholarship committee will be announced by December 18, 2017. Payment will be made directly to the

student’s university or technical school by December 31, 2017. Mail application to: Sandra Hibner, One Children’s Plaza, Dayton, OH 45404

Name ______

Address ______

______

Phone ______

Email address ______

Bleeding Disorder diagnosis ______

Hematologist or HTC ______

High School (if recent graduate), or College currently attending (circle your choice)

______

______

Major ______

I will be a Freshman, Sophomore, Junior, Senior or Senior five-year (circle your choice)

Year of anticipated graduation ______

Number of years (including this one) that you have attended FAMOHIO ______

Essay question: Please limit your response to 400 words or less. Please type your response, doublespaced, on a separate sheet of paper. List your goals, aspirations, and choice of major. Discuss how having a bleeding disorder has affected or inspired your decision to further your education. As an attendee at FAMOHIO 2017, please list the educational sessions and/or young adult activities in

which you participated. Please tell us what you feel you gained from those sessions or experiences.

Please list the activities in which you have participated, including those associated with the bleeding disorders community, during yourhigh school/college years.