memorial scholarship program - matrix …1000 scholarship for men with hemophilia or von willebrand...

At Matrix Health Group our Mission is to provide individualized, focused services to people with bleeding disorders nationwide. Our Vision is to enhance the lives of those we are privileged to serve by providing the best pharmacy and support services possible. Our Mission and Vision are met by the value we place in five Guiding Principles. One of these principles is Enrichment. We understand that in order to perform at our best, we must always seek to learn and grow, while using our knowledge to assist and empower others. In acknowledgement of our Guiding Principle of Enrichment, the Matrix Health Group family of companies offers nine (9) $1000 educational scholarship opportunities to students diagnosed with hemophilia, von Willebrand Disease or other bleeding disorders, and in the case of three of the scholarships, immediate family members may also apply. These scholarships are in memory of several amazing individuals who brought remarkable qualities and skills together in a way that truly touched the community they were dedicated to serving. Their efforts to make a difference in the lives of people with bleeding disorders will not be forgotten and shall be carried on with these scholarship opportunities. Awards are based on criteria including, but not limited to academic merit, reference letters and essay. A Scholarship Committee will review the applications and decide to whom the scholarships will be awarded. Applicants are not required to be past, current or future customers of Matrix Health Group or its companies. Scholarship Programs:

Joe Holibaugh Memorial Scholarship Two $1000 scholarships for MEN and WOMEN with hemophilia AND an inhibitor Joe Holibaugh (1971- 2006) was one of the founding figures of Matrix Health Group. Living with severe hemophilia and an inhibitor, Joe met many challenges. He faced these difficulties as opportunities to grow, embracing life fully with his entire being. Joe worked hard to impart this approach to others, bringing many together with his unique style of wit and humor. Joe’s work lives on in the hearts of his many friends and family who love him dearly. He will always be remembered for his strength, love and resolve to make a difference for the bleeding disorders community.

Tim Kennedy Memorial Scholarship Two $1000 scholarships for MEN with hemophilia Tim Kennedy (1962- 2011) was a tenured employee at Matrix Health Group, and a respected name in the bleeding disorders community. Those who knew Tim remember him for his ability to make most anyone smile and share a hearty laugh. Though life had dealt him a rough hand, Tim kept an air about him that was truly inspiring. As a father and husband, the love he showed his two children and wife knew no bounds. As a friend, he was always ready to listen, share and comfort - most often with his signature sense of humor. As a member of the bleeding disorders community, Tim was devoted to helping his peers look passed their health conditions and enjoy every moment of life for all it’s worth.

MEMORIAL SCHOLARSHIP PROGRAM

Memorial Scholarship Programs


Millie Gonzalez Memorial Scholarship Two $1000 scholarships for WOMEN with hemophilia or von Willebrand Disease Millie Gonzalez (1953-2001) was a devoted wife and mother as well as a pioneer dedicated to advocacy, promoting the awareness of the unique struggles faced by women with bleeding disorders and those tasked with caring for an individual affected by a bleeding disorder. She was married to Papo Gonzalez, a person with severe hemophilia and well known advocate in his own right, who passed prior to Millie. She was a tireless advocate not only for women, but also for persons of Hispanic heritage affected with bleeding disorders. She fought for the inclusion of all persons with bleeding disorders. Although her nature was loving, compassionate and gentle, Millie had the heart of a tiger and fought each day for her own survival while inspiring those around her to achieve and succeed.

Mike Hylton Memorial Scholarship $1000 scholarship for MEN with hemophilia or von Willebrand Disease and their immediate family members Mike Hylton (1945-1998) was a man of great character and steadiness. Mike faced some of the most physically daunting and mortal challenges that people with severe hemophilia could encounter. During the blood crisis of the 1980s, Mike met the challenges he faced with class and a concern for others not only in the bleeding disorder community, but also those affected with HIV. He was a thoughtful, analytical and spiritual individual - patient and tolerant of others, but certainly willing and capable to express his opinions and beliefs. While some felt it was more important to speak, he knew that it was more effective to listen. Mike found great comfort in his faith and family.

Ron Niederman Memorial Scholarship $1000 scholarship for MEN with hemophilia or von Willebrand Disease and their immediate family members Ron Niederman (1950-1999) was born when treatment for persons with bleeding disorders was nonexistent predisposing him as with many of his generation to a lifetime of pain, struggle for better care, and the fight against stigma and prejudice. Living with severe hemophilia, Ron endured challenges well beyond that of most and faced each with grace and an air of, “I can handle that, no problem.” He exemplified the meaning of compassion towards others, action in his words and deeds, and practiced more than preached what it meant to be an advocate locally and nationally. He was a great friend to all that knew him and always a trusted source of advice and wisdom. Ron’s commitment to the bleeding disorder community was surpassed only by his love for his family.

Mark Coats Memorial Scholarship $1000 scholarship for MEN and WOMEN with Hemophilia Mark Coats (1956-1963) was just a child when he passed from hemophilia-related issues. He was born in an entirely different era of bleeding disorder treatment and was not able to live a near normal life as most people with hemophilia do today. With his smiling eyes and sweet grin, we are reminded that every child deserves a chance to lead a full and happy life. We look to Mark as a reminder of what living with a bleeding disorder was like not that long ago, how blessed we are to have the treatments we have today.



Application Requirements:

• Specific eligibility requirement per scholarship as listed in description • Must be a United States resident • Must have applied and been accepted to an accredited college, university or technical school in the United States

on a full-time basis (12 credit hours or more) • Minimum grade point average of 2.5 on a 4.0 scale during entire senior year of high school or current year of

college or graduate school • Employees and family members affiliated with Matrix Health Group or it’s companies are not eligible to apply

Please type or print in ink all information requested. Signed applications and supporting materials must be received by August 1st. The Scholarship Award Committee will meet in September to make a final decision. The applicants awarded the scholarships will be notified by the end of September.

Application Checklist

! Completed, signed and dated 3-page Application

! A recent, full-color, wallet-sized Photograph of yourself, suitable for printing

! 300 to 400 word Essay (Topics are on page 2 of application)

! Letter of Verification from hematologist, physician or treatment center - physician-signed hemophilia “travel” letter is acceptable

! Letter of Recommendation an instructor, school administrator, employer, church leader, volunteer coordinator, or other professional person (Copy of recommendation letter acceptable)

! Copy of most recent Transcripts from high school and college/university/technical school (if already attending). Transcripts do not need to be certified copies

! Copy of ACT or SAT scores (Required for incoming freshman only)

! Proof of Admission to the college/university/technical school (Required for incoming freshman only)

! Affix appropriate postage and submit. Must be postmarked before the August 1st deadline Incomplete or late applications will not be eligible for consideration. Please mail your complete scholarship application packet to:

Matrix Health Group Memorial Scholarship Programs 3300 Corporate Venue, Suite 104

Weston, Florida 33331 For questions, please call, text or email: Maria Vetter: 217-840-1033; [email protected]



Memorial Scholarship Programs MEMORIAL SCHOLARSHIP PROGRAM

Application Form - page 1

Program Selection: Please review the scholarship requirements and indicate the program(s) for which you are applying. Check all that apply - no need to submit separate applications for each program.

! Joe Holibaugh Memorial Scholarship:For MEN and WOMEN with hemophilia AND an inhibitor.

! Tim Kennedy Memorial Scholarship:For MEN with hemophilia

! Millie Gonzalez Memorial Scholarship:For WOMEN with hemophilia or von Willebrand Disease

! Mike Hylton Memorial Scholarship:For MEN with hemophilia or von Willebrand Disease and their immediate family members

! Ron Niederman Memorial Scholarship:For MEN with hemophilia or von Willebrand Disease and their immediate family members

! Mark Coats Memorial Scholarship:For MEN and WOMEN with Hemophilia

Personal Information:

Last Name _______________________________________________ First Name _________________________________ Middle Initial______

Address _________________________________________________ Home Phone ___________________________________________________

_________________________________________________ Cell Phone ____________________________________________________

Email Address ___________________________________________ Date of Birth _________________________ ! Male ! Female

Bleeding Disorder ! Hemophilia A ! Hemophilia B ! von Willebrand –Type ___________________________

Severity ! Mild ! Moderate ! Severe ! Inhibitor Age at diagnosis _________________

Physician Name and Phone Number _____________________________________________________________________________________

Hemophilia Treatment Center (if applicable)_______________________________________________________________________________

____________________________________________________________________________________________________________________________

Scholarship:

How did you hear of the Matrix Health Group Memorial Scholarship programs?

! Matrix Health Group News newsletter

! Matrix Health Group Face Book

! Online Scholarship Search (please name search engine) _____________________________________________________________

! Matrix Health Group personnel (please name) ________________________________________________________________________

! Chapter or Foundation (please specify) _______________________________________________________________________________

! HTC Personnel (please name _________________________________________________________________________________________

Memorial Scholarship Programs MEMORIAL SCHOLARSHIP PROGRAM

Application Form - page 2

Educational Information:

Last school attended __________________________________________________ City and State ____________________________________

Graduation Date ____________________________ ACT or SAT Score (if incoming freshman) ACT _____________ SAT _____________

Cumulative High School or current college/school Grade Point Average __________________ Grading Scale _________________

Planning, or are attending: ! Graduate School ! University/College ! Jr. College ! Tech/Trade School

School Name __________________________________________________________ City, State _________________________________________

Formally accepted? ! Yes ! No Field of Study: Major _____________________________________________________________

At the beginning of the next school year, what year will you enter?

! Freshman ! Sophomore ! Junior ! Senior ! Graduate Student Expected date of graduation ______________

Work Experience: Please list any jobs you have held, your job title, duties and dates of employment. A resume or additional sheet may be substituted for this section.

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

Volunteer Experience: Please list any volunteer positions you have held. A resume or additional sheet may be substituted for this section.

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

Essay: Please choose one topic and submit a typed essay of 300-400 words. Please attach as a separate sheet and sign your name at the bottom of your essay.

1.) How do you feel your life has been influenced by having a bleeding disorder (or by having a bleeding disorder in your family)

2.) What has been your biggest challenge in regards to having a bleeding disorder and how have you or are you working through it?



Application Form - page 3 Certification and Release

A Scholarship Committee will review all completed Matrix Health Group Memorial Scholarship Program applications and will determined the award recipients. It may be necessary for someone from the Scholarship Committee to contact you for a personal interview or to qualify any information contained within your application. All decisions made by the Scholarship Committee are final. I certify all statements contained in the foregoing application are true and correct, and have personally signed this Matrix Health Group Memorial Scholarship Programs application. In consideration of my acceptance of this scholarship, should I be selected as an award recipient, I agree to all the conditions set forth, and further agree to grant all permission to Matrix Health Group, its companies and the Memorial Scholarship Programs, to any and all the foregoing, to use any photographs, quotes contained herein, and statements for use in social media, publications, website, promotional materials and advertising for any purpose of announcing the scholarship and its recipients. Authorization for Media Release I hereby authorize BioMatrix, and its representatives or agents, to use and disclose information about me or my child, including protected health information as defined by federal and state law, for use in publications and to the general public or media. The information may include my or my child’s name, age, treatment, duration of treatment, treatment plan, diagnoses, medication, city and state of residence, photographic images, video, audio, identifying information, and other information about my or my child’s life and experience as a patient of BioMatrix. The information may also be disclosed to external media and may be disclosed in the following, but not limited to, forms: press releases, stories, photographs or video clips. It may also be used for publications produced by or on behalf of BioMatrix, including but not limited to advertising, promotional and marketing materials (“Materials”). Such Materials may include sales and educational brochures, display boards, sales campaigns, promotional items, company newsletters, social media, and websites. I authorize BioMatrix to use, reuse, copy, publish, display, exhibit, reproduce, license to third parties, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to articles, magazines, advertisements, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I understand that I will not be compensated in any way for the taking or use of my or my child’s information, photographs, films, audio, and/or video. I understand that BioMatrix will not condition treatment on my provision of this authorization. I understand that any information used or disclosed pursuant to this authorization is no longer protected by federal law and may be re-disclosed. Waiver and Release from Liability In consideration of the parties’ mutual promises, the sufficiency of which is hereby acknowledged, I waive any and all claims that I, my heirs and assigns may have, now or in the future, against BioMatrix, its affiliates, employees, agents or assigns and release BioMatrix from any and all liability from damages, arising from or relating to BioMatrix’s use and disclosure of my protected health information, identifying information, and photographs or images as described above. I understand that this authorization is voluntary, and that I may revoke the authorization at any time by presenting my written revocation to BioMatrix. To do so, I must send a written notice to the BioMatrix Privacy Officer at 3300 Corporate Avenue, Suite 104, Weston, FL 33331. I understand that such revocation will not apply to information that has already been released in response to this authorization. __________________________________________________ __________________________________________________ _____________________ Applicant’s Printed Name Applicant’s Signed Name Date

If applicant is under age 18, please include a parent or guardian’s signature __________________________________________________ __________________________________________________ _____________________ Parent or Guardian Printed Name Parent or Guardian Signed Name Date

__________________________________________________ __________________________________________________ Parent or Guardian Phone Number Basis of Authorization (i.e. – Parent, Guardian)



MEDICAL VERIFICATION FORM Physician or Treatment Center

Dear Applicant: Please fill out your name and address and give this form to your physician or hemophilia treatment center. A copy of a letter signed by your physician or treatment center (such as a travel letter) verifying your bleeding disorder may be substituted for this form. It is your responsibility to see this form is submitted by the August 1st deadline. Name of Applicant ________________________________________________________________________________________________________

Address of Applicant ______________________________________________________________________________________________________

To be completed by applicant’s Physician or Nurse What type of bleeding disorder has this scholarship applicant been diagnosed with?

! Hemophilia A ! Hemophilia B Severity: ! Mild ! Moderate ! Severe

Inhibitor: ! Yes ! No

! von Willebrand ! Type 1 ! Type 2 ! Type 3 Severity___________________________

! Other (please specify)___________________________________________________________________________________________________ ____________________________________________________________________________ _____________________________________________ Physician/Nurse Signed Name Date ____________________________________________________________________________ _____________________________________________ Physician/Nurse Printed Name Phone number

____________________________________________________________________________________________________________________________ Treatment Center or Medical Facility ____________________________________________________________________________________________________________________________Treatment Center or Medical Facility Address

Please return this form to the student for mailing by the August 1st deadline.

You may also mail the Medical Verification directly to the Scholarship Committee:

Matrix Health Group Memorial Scholarship Programs 3300 Corporate Avenue, Suite 104

Weston, Florida 33331 For questions, please call, text or email: Maria Vetter: 217-840-1033; [email protected]



RECOMMENDATION FORM

Instructor, School Administrator, Employer, Volunteer Coordinator, Church Leader

Dear Applicant: Please fill out your name and address on this form and give it to the person you have requested to submit your recommendation. A signed letter of recommendation may be substituted for this form or attached as additional information. It is your responsibility to see that the recommendation is submitted by the August 1st deadline.

Recommendation:

Name of Applicant _________________________________________________________________________________________________________

Address of Applicant ______________________________________________________________________________________________________

What is your relationship to the above applicant? _________________________________________________________________________

How long have you known the applicant? ________________________________________________________________________________

What are the applicant’s most significant talents? If more space is needed, please continue on reverse side or attach a letter.

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________

____________________________________________________________________________ _____________________________________________ Email address Phone number ____________________________________________________________________________ Printed Name ____________________________________________________________________________ _____________________________________________ Signed Name Date

Please return this form to the student for mailing by the August 1st deadline. You may also mail the Medical Verification directly to the Scholarship Committee:

Matrix Health Group Memorial Scholarship Programs

3300 Corporate Avenue, Suite 104 Weston, Florida 33331

For questions, please call, text or email: Maria Vetter: 217-840-1033; [email protected]

memorial scholarship program - matrix …1000 scholarship for men with hemophilia or von willebrand...

Documents