Brookestrong Scholarship Award Information Sheet Brookestrong Foundation 30-6421123 The Brookestrong Foundation was created in honor of 19 year old Brooke Dawkins. On February 23, 2014, Brooke was struck by a vehicle while crossing Alafaya Trail near the University of Central Florida. As a result of the accident, Brooke suffered a severe traumatic brain injury (TBI) and was treated in the Intensive Care Unit at Orlando Regional Medical Center. During treatment for her TBI, Brooke s medical team also discovered a ruptured aneurysm in her brain, which was surgically repaired. The doctors and nursing staff at Orlando Regional Medical Center worked tirelessly to provide a positive outcome for Brooke. Tragically, her injuries were too severe and resulted in a complete and irreversible loss of brain function. On March 5, 2014, Brooke was declared brain dead. The Brookestrong Foundation has been established as an eternal tribute to Brooke. The Foundation was created exclusively for the purposes authorized under Section 501(C)(3) of the Internal Revenue Code. Scholarship Program To award financial scholarships to high school seniors and at least half-time college students pursuing a degree that have experienced a serious brain injury or ruptured aneurysm that they must overcome or have overcome to pursue their education. Amount to be Awarded The Trustees have authorized a scholarship amount of $1,500 for the 2016 Fall Semester. In setting the amounts to be awarded, a minimum amount of scholarship is noted, with possible greater amounts awarded but not an amount that exceeds the student s tuition costs for the award year (e.g. fall and spring semester). Application Deadline: April 30, 2016 (Must be postmarked or emailed prior to or on this date) The scholarship is anticipated to be awarded By June 15, 2016. The award will be distributed directly to the school for the benefit of the student upon receipt of sufficient documentation as determined by the Trustees that the student is enrolled at least half-time in an accredited college or university, community college, or technical school. Eligible students Applicants must have suffered a brain injury or ruptured aneurysm, be a US citizen, and meet one of the following categories: 1
Brookestrong Scholarship Award Information Sheet Brookestrong Foundation 30-6421123 William R. Boone High School seniors that have been accepted into an accredited college or university, community college, or technical school that meets the requirements of IRC 170(b)(1)(A)(ii). At least half-time students that have been accepted to, or attend the University of Central Florida. A member in good standing with an affiliated chapter of Kappa Delta Sorority or Alpha Tau Omega Fraternity. Award Evaluation Criteria The student s academic performance before and after the injury. Extent of circumstances and challenges faced and severity of the injury as detailed in essay. The applications and essay will be evaluated by a committee appointed by the Trustees (Committee). Relatives of the Committee or Trustees are not eligible for the award. If an application meeting the minimum evaluation criteria is received, the Committee will recommend at least one scholarship to be provided, if in the Committee s opinion, more than one applicant is deserving based on the circumstances of the applications, multiple recommendations may be made to the Trustees. The final decision and the amounts to be awarded (at least the minimum amount noted) to the students will be based on the vote of the Trustees. The notification will be sent to the winning applicant and an official notice will be placed on the Foundation s website by June 15, 2016. If any information submitted for this scholarship award is later deemed to be inaccurate, the Trustees may ban the individual from applying again, and the Trustees may, at their discretion and in the best interest of the Foundation, seek all legal remedies for return of the funds. 2
Brookestrong Foundation Scholarship Application Brookestrong Foundation 30-6421123 Thank you for taking time to apply for the Brookestrong Foundation Scholarship. This scholarship is for high school seniors and at least half-time college students pursuing a degree that have experienced a brain injury or ruptured aneurysm that they must overcome or have overcome to pursue their education. For specific eligible student criteria, please see the Scholarship Award Information Sheet. Once completed, please submit all your information to the Brookestrong Foundation as follows: By Mail: By Email: The Brookestrong Foundation 3842 Gatlin Woods Drive Orlando, FL 32812 Brookestrongnow@gmail.com 1. Applicant s Full Name: LAST NAME FIRST NAME MIDDLE INITIAL 2. Applicant s Complete Address: STREET ADDRESS STREET ADDRESS (SECOND LINE) CITY STATE/PROVINCE POSTAL CODE/ZIP CODE PHONE E-MAIL ADDRESS Page 1 of 4
Brookestrong Foundation 30-6421123 3. Submission requirement from information sheet for school or membership from definition of Eligible Students (must meet at least one). William R. Boone High School Senior UCF Applicant or Student Member in Good Standing Alpha Tau Omega Fraternity Member in Good Standing Kappa Delta Sorority 4. Country of Citizenship 5. Date to graduate (or graduated) from high school: 6. Date to enter (or entered) college or technical school: 7. Name of college(s) (currently attending or applying to) and proof of or means to verify the accreditation of the college (if applicable): 8. Number of years of college or technical school completed (if any): 9. Copy of high school or college transcripts to demonstrate performance in school. 10. Provide any test scores, such as your official SAT, ACT, or other academic measures. (Please send us a copy of your official scores as soon as you have them.) Test and Score Date 11. List your extracurricular activities in high school or post secondary education (include any descriptions or details as attachments): Page 2 of 4
Brookestrong Foundation 30-6421123 12. What is the title of your personal essay on the circumstances and challenges faced as a result of your injury? The essay should include sufficient details of the severity of the injury to enable the Foundation to evaluate the severity of the challenges you needed (or will need) to overcome. In addition, we request you include documentation that will enable the Foundation to ensure that a qualifying injury occurred. If, in the opinion of the Committee, sufficient documentation of the qualified injury is not provided (or other information is not complete), the Committee will attempt to contact the Applicant to obtain additional information prior to disqualification of an application. If an Applicant is contacted for additional information and in the opinion of the Committee sufficient information is not provided, the Applicant will be notified in writing that he/she is not eligible for consideration of the award. As this document will become part of the permanent scholarship application record, any details of Personal Health Information defined under the Health Insurance Portability and Accountability Act (HIPAA) regulations are not required. Details included in the written essay will become part of the permanent scholarship application and could be subject to public inspection under the rules for 501(C)(3) Organizations. Therefore, the applicant needs to sign the release form attached to this document (Include actual written essay as an attachment, at most 4 pages, single-spaced, 12-point type; may be less, such as double-spaced, etc.). The Foundation understands that someone s injury could preclude or hinder them from completed an essay. If that is the case, please explain and provide requested information by alternative means. 13. Submit one letter of personal recommendation from someone familiar with your injury and efforts to overcome. Page 3 of 4
Brookestrong Foundation 30-6421123 ASSIGNMENT OF RIGHTS & CONSENT TO PUBLISH SCHOLARSHIP INFORMATION AND PERSONAL HEALTH INFORMATION INCLUDED IN ESSAY RELEASE DOCUMENT I (If applicant is a minor, then this authorization must be completed by the applicant s parent or legal guardian) certify that all information contained in this application is accurate and give full rights to The Brookestrong Foundation Trustees to publish the scholarship applicant s name and any information contained in my application. In addition, I do hereby grant, authorize, and agree to hold harmless the Brookestrong Foundation Trustee and Committee members for releasing and publishing any information contained in my essay or application, that at the sole discretion of the Trustees, is relevant to the award; regardless if such information could be considered Personal Health Information under the Health Insurance Portability and Accountability Act (HIPAA), as amended. I also understand that my application and related essay may be subject to inspection by members of the public in accordance with the requirements for 501(C)(3) organizations. I acknowledge that the information provided in this application was disclosed willfully. Date:. By: Print Name (If applicant is minor, legal guardian or parent name) Signature Relation to applicant if applicant is under the age of 18 Witness: Print Name Signature Page 4 of 4