Balding for Dollars - Bursary Application General InformationApplication Date(Required) MM slash DD slash YYYY Recipient Name(Required) First Last Primary Email(Required) Secondary Email (alternate contact)Phone Number(Required)Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Select which term you are applying for(Required)Winter/Spring – Nov. 15 deadlineSummer/Fall – June 15 deadlineHow did you hear about this bursary?Eligibility CriteriaSelect which option applies to you:I am a survivor or childhood cancer, or a blood disorder & was treated at BCCHI am in treatment at BCCH for childhood cancer or a blood disorderI am a sibling of a past/current BCCH cancer or blood disorder patientHow many times have you received a Balding for Dollars bursary award?Never1xMore than 2xMore than 5xHave you volunteered for Balding for Dollars in the past year?YesNoIf no, when was the last year you volunteered?BCCH DoctorLast year of treatmentEducation InformationWhat school will you attend?What is your program of study?How long is your program?Estimated tuition?RequiredLetter of Acceptance from educational institutionAccepted file types: pdf, Max. file size: 50 MB.PDF Document Must Be UploadedConsent 1(Required) I hereby certify that the above information is true and correct, and I understand that any false statement(s) may disqualify me from receiving this bursary. Consent 2(Required) I understand that it is my responsibility to complete the Bursary Payment Request form by the deadline date for payment of the bursary to be processed. Further, I understand that late forms will not be accepted and will result in my bursary award being forfeited. Consent 3(Required) I hereby give Balding for Dollars permission to use my name and image on promotional materials, including print, online and social media, in association with any testimonials I have given to promote Balding for Dollars programs. Please tell us about your and your family’s experience with Balding for Dollars. Which program(s) did you find most beneficial? What else could we do to support you?Date MM slash DD slash YYYY Number
