2014 United Breast Cancer Foundation Scholarship Program Omega Institute, Rhinebeck, NY Campus

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1 1 Dear Scholarship Applicant, 2014 United Breast Cancer Foundation Scholarship Program Omega Institute, Rhinebeck, NY Campus The United Breast Cancer Foundation (UBCF) and the Omega Institute for Holistic Studies (Omega) have proudly been in partnership since Through this partnership, UBCF is pleased to provide two distinct scholarship opportunities providing financial assistance to women and men who wish to participate in classes, seminars, workshops and other learning opportunities focused on holistic healing, health, and wellbeing at Omega s Rhinebeck, New York campus. Below are descriptions of UBCF s two scholarship programs. Please check the box for the scholarship you are interested in applying for. Please choose only one scholarship opportunity. I would like to apply UBCF Rejuvenation Scholarship Available to women and men currently managing breast cancer or within 5 years remission Includes program tuition, meals, and dorm accommodations for a weekend workshop of your choice Required income verification of your last two pay stubs Required letter from your doctor documenting your current health status including your remission date if applicable Application (including sections C1 and D on page 3) and personal essay I would like to apply UBCF & UWHA! Connect to Y.E.S. Scholarship Available to women and men regardless of age or health status Includes tuition for Connect to Y.E.S Through Emotional Fitness, Course # SM , September 21-26, (Meals and accommodations are not included.) Required income verification of your last two pay stubs Application (including section C2 on page 3) and personal essay Thank you for your interest in the UBCF Omega scholarship program. We are so glad you want to join us and experience all Omega has to offer. Your scholarship request is important to us and will be carefully considered. You will be notified by that we have received your application within 48 hours of receipt of your application. Sincerely, Omega Institute Scholarship Program & The United Breast Cancer Foundation

2 UBCF Scholarship Program Omega Institute, Rhinebeck, NY Campus All questions (including essay) must be completed. Please write clearly. A: Applicant Information: Name: Address: City: State: Zip: Phone (AM) (PM) Occupation: Employer: Gender: Female Male Age: (Optional) and over Ethnicity: (Optional) American Indian/Alaska native Hispanic/Latino Asian/Pacific Islander White/Caucasian Black/African American Multi-ethnic Other, please specify Total Household Gross Annual Income as reported on most recent tax forms: $ Total number of people in household (as shown on tax forms): Household Size To be eligible for a scholarship your maximum household income cannot exceed: 1 $27,225 2 $36,775 3 $45,325 4 $55,875 5 $64,425 6 $74,975 To verify your income, please submit the last two pay stubs or other documentation of income for your household. See pg 5 for more information on this requirement.

3 3 B: Please answer the following: Are you a returning UBCF scholarship recipient? Please let us know how you learned about this opportunity: C: Course Selection: 1) Please complete ONLY if you are applying for the UBCF Rejuvenation Scholarship. Which course are you applying for? Course #: Title/Faculty: Dates: Tuition Cost: $ Material Fee: $ (If applicable) 2) Please complete ONLY if you are applying for scholarship to the UBCF & UWHA! Connect to Y.E.S. Through Emotional Fitness TM program with Andrea Becky Hanson, held 9/21/14 9/26/14: Have you worked with Andrea Becky Hanson previously? If so, when and where? D: Accommodations: Please complete ONLY if you are applying for the UBCF Rejuvenation Scholarship If you would like a DORM and can bring your own towel and sheets or sleeping bag, please check here If you will be commuting and will be staying off campus, please check here E: Special Needs: If you have any special needs, please describe:

4 4 F: Personal Essay: The determining factors in awarding scholarships take into account the financial need, personal desire and/or professional commitment of each applicant. If you have met the income eligibility criteria, please take the time to briefly describe why you should be considered for this United Breast Cancer Foundation scholarship. Please write legibly. Eligibility:

5 5 Eligibility is based on a first come, first served basis and is primarily determined based on financial need. Financial need is defined at 2 1/2 times the Federal Poverty level, as set forth in US Federal Guidelines (see application). Please note: this determines your financial eligibility only and does not guarantee a scholarship. The high demand and limited funds available for scholarships requires that we adhere to these guidelines. Please note: Only one scholarship per applicant will be awarded (pending eligibility and availability of funding). Scholarship only covers the applicant. It does not cover children, family members or anyone who may be coming with the applicant. Registration: Submitting an application for a scholarship does not register you for the course. When a scholarship has been awarded, we will register you and send you a letter of confirmation. Once you have received your letter, you will have two weeks to call Omega and confirm your intention to attend the course, and pay any outstanding balance. Additional Documentation: You must submit the following with your application: 2 pay stubs per adult in the household (for both scholarships) Letter from your doctor documenting health status (for UBCF Rejuvenation Scholarship only) I certify that all of the above information is true and correct and that all income is reported. I understand that this information will be kept strictly confidential and is only used in determining scholarship eligibility. Signature: Date: Return this form to: Omega Institute Scholarship Program 150 Lake Drive Rhinebeck, NY Fax: If you have any questions or require additional information, please call: ext. 180

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