ucbeyond 2013 scholarship application
TRANSCRIPT
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7/30/2019 UCBeyond 2013 Scholarship Application
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UCBeyond 2013 Scholarship Program ApplicationBecause a Disease Shouldnt Disable an Education
CRA SCRCANADIAN
RHEUMATOLOGYASS OC IAT IO N
S O C I T
CANADIENNEDE RHUMATOLOGIE
Purpose and AwardUCB Canada Inc., a global biopharmaceutical company committed to developing innovative treatments or inammatory diseases such as rheumatoid ar thritis,
is dedicated to creating unique programs and tools to aid patients in reaching above and beyond the boundaries o their disease and ulflling their educational
ambitions. Now in its seventh year, the UCBeyond Scholarship Program has allocated 116 scholarships and approximately $585,000 CAN to Canadian students.
Eligibility RequirementsThis program is designed or applicants o any age. Applicants must be:
A legal and permanent resident of Canada;
Diagnosed with inammatory arthritis by a physician; Seeking an associates, undergraduate, or graduate degree from a Canadian university; a diploma or cer ticate from a Canadian college; or enrolled in a trade
school educational program;
A student who demonstrates academic ambition and embraces a way of life that goes above and beyond the boundaries of living with inammatory arthritis; a Enrolled in or awaiting acceptance from a Canadian-based institution of higher education for the fall semester of 2013.
The Selection of Recipients and Determination of the Scholarship AmountEmployees of UCB Canada Inc. and their immediate family members are not eligible for this scholarship. Selection of recipients will be at the sole
discretion o an independent selection committee, comprised o medical proessionals and patient representatives. Winners will be notifed during the
month of August 2013 via a personal telephone call and a conrmation letter. After a winners educational enrollment has been veried for the fall 2013
semester, the scholarship cheque will be made payable to and directly mailed to the educational institution. Individual scholarship amounts will be awarde
up to $5,000 CAN to cover the recipients tuition and/or educational materials and expenses (if a student does not have a minimum of $5,000 CANin tuition and educational material costs, the scholarship amount will only cover the actual cost of tuition and/or educational material expenses up to
$5,000 CAN). A student will not be disqualied if they have been a recipient of the UCBeyond Scholarship in the past, although this information will be taken
into account throughout the selection process. Preerence will be given to applicants who have not previously been awarded the UCBeyond Scholarship.
ProceduresTo apply, please submit the following documentation postmarked byJune 30, 2013.
Please note that sections o the application will need to be completed by the student, a school ofcial or proessional colleague, and a health care proessional.
Selection will be based on the ollowing criteria, which must be included:
A one-page essay about how you are living above and beyond the boundaries of inammatory arthritis to demonstrate academic ambition and personal
achievement, and how you would beneft rom the Scholarship. Past recipient essays have included a desire or academic achievement, perseverance in the ac
of inammatory arthritis and details of school and community involvement;
Two (2) one-page letters of recommendation from a teacher, school ofcial, professional colleague, employer or friend describing your unique qualities
and how you embrace a way of life that overcomes the boundaries of living with inammatory arthritis; An ofcial academic transcript from your most recent year of education; and
Conrmation of diagnosis from your treating physicianThe above documentation will be destroyed by UCB Canada Inc. upon selection o the Scholarship recipients.
Student Information(please print)
Name ________________________________________________________Student ID #
Home Address (No P.O. Boxes)
City _____________________________________________ Province_______________ Postal Code
Date of Birth (MM/DD/YY) ________/_______/_______ Please check one: Male Female Email Address____________________________Home Phone __________________ Cell Phone
(To be signed i applicant is 18 years o age or older)
Please enter my application in the UCBeyond 2013 Scholarship Program. I conrm that I am 18 years of age or older and that I meet the eligibility requirements.I certiy that I am not a UCB Canada Inc. employee or an immediate amily member o a UCB Canada Inc. employee.
Signature ___________________________________________________________________Date______/_________/_______
(To be signed by Parent/Guardian i applicant is less than 18 years o age)Parent/Guardian Permission: I acknowledge that I am the parent or legal guardian of the applicant and, in that capacity, understand the conditions under whichhe/she is entering his/her application in the UCBeyond 2013 Scholarship Program.
Parent/Guardian Signature ______________________________________________________ Date______/_________/_______
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7/30/2019 UCBeyond 2013 Scholarship Application
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UCBeyond 2013 Scholarship Program ApplicationBecause a Disease Shouldnt Disable an Education
CRA SCRCANADIAN
RHEUMATOLOGYASS OC IAT IO N
S O C I T
CANADIENNEDE RHUMATOLOGIE
Section I: Academics(To be completed by the student)
Name of post-secondary educational institution:
What type o degree are you pursuing? Associates Undergraduate Graduate Certifcate
What year of your degree will you be in the fall semester of 2013? ________________
School Address:
City _________________________________________________Prov. _______________________ Postal Code
Your Address at School:
City _________________________________________________Prov. _______________________ Postal Code
Honours and Achievements:
All Scholarships / Grants Applied for or Received:Title Amount _____________________________________________________ Date_____/_____/_____Received
Title Amount _____________________________________________________ Date_____/_____/_____Received
Title Amount _____________________________________________________ Date_____/_____/_____Received
Title Amount _____________________________________________________ Date_____/_____/_____Received
(To be completed by your school ocial)
Academic Standing
Applicants Major ________________________________________________Minor
Applicants Grade Point Average __________________________________ on a scale o
Signature (School Ofcial)
Title
Date_____/_____/_____
Please provide an ofcial academic transcript. Transcripts may be mailed separately. Transcripts must be
postmarked by the application deadline,June 30, 2013.
Section II: Recommendations(To be completed by a teacher, school ocial, proessional colleague or employer)
Please provide two (2) one-page letters of personal recommendation that express the following: The nature of your relationship with the applicant
The applicants unique qualities and how he/she embraces a way of life that overcomes the boundaries of living with inammatory arthritis
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UCBeyond 2013 Scholarship Program ApplicationBecause a Disease Shouldnt Disable an Education
CRA SCRCANADIAN
RHEUMATOLOGYASS OC IAT IO N
S O C I T
CANADIENNEDE RHUMATOLOGIE
Section III: Health(To be completed by a health care proessional who can conrm the infammatory arthritis diagnosis)
Patients Medical Summary:
I certiy that this applicant has been diagnosed with inammatory arthritis and is under my medical care.
Name
Ofce Address _______________________________________________________________________________City
Prov. _______________________________________ Postal Code ___________________Telephone
Signature ____________________________________________ Credentials ___________ ___________Date _____/______/______
Section IV: Documents Provided By the Student Applicant
Please submit a one-page essay about how you are living above and beyond the boundaries of inammatory arthritis to demonstrate academic ambition apersonal achievement and how you would benet from the scholarship. Please note, essays that exceed one-page, font size smaller than 11pt or margins le
than one inch, will not be eligible or consideration.
Section V: Applicant Consent
By signing below, the applicant authorizes UCB Canada Inc. and all their afliates, if awarded the UCBeyond Scholarship, to publish, copyright, and use the
inormation contained in this application in advertising and other promotional materials without prior approval, including display on the Internet. UCB Canada
Inc. is authorized to share the applicants information and individual story with the mass consumer media. The applicant authorizes UCB Canada Inc. to contacthim/her directly and to enter the applicants contact information into a UCB Canada Inc. patient database for future communications from UCB Canada Inc.
In addition, recipients may be called upon to share their stories with the mass consumer media (print, radio or television) either by phone or in person,about living with inammatory ar thritis to help inspire others struggling to fnd ways in which to cope with the disease. Participation in the matters outlined
in this paragraph is a condition to receipt o the Scholarship. Should the applicant be unwilling or unable to comply with the requirements o this paragraph
an alternate Scholarship recipient may be selected.
Employees of UCB Canada Inc. and their immediate family members are not eligible for this scholarship. Selection of recipients will be at the sole
discretion o an independent selection committee , comprised o medical proessionals and patient representatives. Winners will be notifed dur ing
the month of August 2013 via a personal telephone call and a conr mation letter. After a winner s educat ional enrol lment has been veried for the
fall 2013 semester, the scholarship cheque will be made payable to and directly mailed to the educational institution. Individual scholarship amounts
will be awarded up to $5,000 CAN to cover the recipients tuition and/or educational materials and expenses (if a student does not have a minimumof $5,000 CAN in tuition and educational material costs, the scholarship amount will only cover the actual cost of tuition and/or educational materia
expenses up to $5,000 CAN). A student will not be disqualifed i they have been a recipient o the UCBeyond Scholarship in the past, although
this information will be taken into account throughout the select ion process. Preference will be given to applicants who have not previously been
awarded the UCBeyond Scholarship.
By signing, the applicant authorizes the school to share information with UCB Canada Inc. and its afliates regarding the number of classes left to complete
his/her degree and the cost per class and other information necessary to process the Scholarship.
Signature _________________________________________________________________Date ______/_______/_______
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7/30/2019 UCBeyond 2013 Scholarship Application
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UCBeyond 2013 Scholarship Program ApplicationBecause a Disease Shouldnt Disable an Education
CRA SCRCANADIAN
RHEUMATOLOGYASS OC IAT IO N
S O C I T
CANADIENNEDE RHUMATOLOGIE
Checklist for submission Completed application orm
One-page essay
Ofcial academic transcript Confrmation o inammatory ar thritis diagnosis rom your treating physician
Two (2) one-page letters of personal recommendation from a teacher, school ofcial, professional colleague or employer
How did you learn about the UCBeyond Scholarship Program? Doctors Ofce
Media
Social Media (Facebook)
Internet
The Arthritis Society
Canadian Arthritis Patient Alliance
Arthritis Consumer Experts
Other (please specify) _____________________________________________________
Have you applied for the UCBeyond Scholarship in the past?
Yes
No
Thank you for applying for the
UCBeyond 2013 Scholarship Program
Please visit us on Facebook by searching UCBeyond
We wish you the best of luck!
Please send completed application to:
UCBeyond 2013 Scholarship Program109 Thomas Street
PO Box 69624Oakville, ON L6J 7R4
Be sure to complete and postmark the application byJune 30, 2013.
For more inormation, please contact: UCBeyond Scholarship Program, [email protected], 1-855-UCBYOND (822-9663www.ucbeyond.ca
2013 UCB Canada Inc.Oakville, ON
All rights reserved.