Pam King HAEA Scholarship Program

On-Line Application

Documents required to submit an application:
•   A physician's statement noting applicant’s HAE diagnosis (reapplicants are not required to submit physician's statement)
•   Current FASFA Summary Report (report must include adjusted household income)

After submitting this form, you will receive an email with additional links that will be associated with your application. You must forward one link to a school counselor or reference, and the other to a faculty member who will use it to upload your transcripts.

Please complete the entire application form. If something is not applicable, please mark "N/A".
Carefully follow all of the directions provided for each section before submitting your application.


Applicant Information
First Name:   Last Name:   Middle Initial: 

Address: 
 
City 
State    Zip Code: 

Date of Birth:    Sex: Male Female
Telephone number: 
E-mail address: 

If you have completed two or more semesters of college, please enter the name of that college instead of your high school information below.
Name of School Attended: 
Address: 
 
City 
State    Zip Code: 
Number of Years Attended: 
Graduation Date: 

Do you feel that your grades are an accurate index of your ability? Yes No
If not, what circumstances do you feel have affected your scholastic record?



School Name for which you are applying for the scholarship
(if different from above):
Area of study: 



Activities Awards and Honors
Please list all school activities in which you have participated during high school (i.e., student government, music, etc.) and college, if applicable.

Activity No. Years    Awards / Honors Offices Held Add row

Please list all community activities in which you have participated without pay during school (i.e., civic involvement, volunteer work, etc.).
Organization No. Years    Awards / Honors Describe Involvement Add row


Work Experience
Please list all work experience.

Company Position    Start Date End Date Avg. Hours/Week Add row


Applications for Scholarships/Grants/Financial Aid From Other Organizations
List all scholarships, grants and financial aid programs that you have applied for and indicate amount awarded or indicate amount for which you are still waiting for notification.


Name of Scholarship/Grant/Financial Aid Program Amount Applied For    Amount Awarded Add row


In approximately 500 words or less, please outline how you deal with life's hurdles - especially in terms of living with HAE - and your aspirations for the future. If you are applying for a scholarship a second time, you do not have to write a new essay. Please just enter "re-applicant" in the field below.

0 words



A FAFSA Summary Report is to be submitted with this form as follows:
All Scholarship applicants are required to provide a FAFSA (Free Application for Federal Student Aid) Summary Report.
Please go to https://fafsa.ed.gov to begin the FAFSA application. Once completed, FAFSA will email you a Summary Report. Please scan your Summary Report and save it to your computer. Then upload it here.

I have completed my FAFSA application and am including it with this application.

I have completed my estimated FAFSA form. I will submit all the tax returns required by FAFSA to them by April 15th. I will submit a revised and final FAFSA to the HAEA Scholarship Committee by emailing it to HAEScholarship@gmail.com, once it has been received by me. I understand that failure to submit the required information may be cause for withdrawal of any consideration for a scholarship.



Physician's Statement
I have a statement from my physician stating that I have been diagnosed with Hereditary Angioedema and am being treated by him/her.  I understand that a physician's statement is required for my application to be considered by the Scholarship Committee.

Please scan your Physician's Statement and save it to your computer. Then upload it here.



Certification and Consent to Release Information
By signing below, the applicant certifies that all statements submitted are true and correct, that he/she believes that he/she is eligible, to apply for an HAEA Scholarship.

According to the Federal Family Rights and Privacy Act of 1984, no information about a student's academic performance may be disclosed without the written consent of the student, if he/she is 18 years of age or older, or the consent of his/her parent, if the student is under the age of 18.

Therefore, to complete the HAEA Scholarship Program Application, a signature must be provided prior to the school registrar/principal/guidance counselor providing the additional information required by this application.


Applicant Signature:    Date: 
(By entering my name and today's date in the above field, I provide an electronic signature of consent and agreement.)

Parent/Guardian Signature:  (if applicant is not yet 18)   Date: 
(By entering my name and today's date in the above field, I provide an electronic signature of consent and agreement.)


All information submitted is for the sole use of the HAEA Scholarship Committee to determine award winners. Information contained and submitted with this application will be kept confidential and will not be used for any other purpose.