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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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



(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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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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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.

UCBeyond 2013 Scholarship Application

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Transcript of UCBeyond 2013 Scholarship Application