Pediatric Scholarship Application

Please fill out the following form to help us understand your physical condition.

Applicant's First Name

Applicant's Last Name

Guardian's/Parent's First Name

Email Address

Guardian's/Parent's Last Name

Applicant's Date of Birth

1.) Is the applicant currently awaiting any of the following? (Select only one)

2.) Has the applicant undergone a bowel resection (surgery)?

No

Yes

3.) Does the applicant have a diagnosis of Short Bowel Syndrome?

No

Yes

If you answered yes, please provide date of diagnosis.

4.) Is the applicant Total Parenteral Nutrition (TPN) dependent?

No

Yes

5.) Has the applicant lost any standard central venous access sites?

No

Yes

6.) Does the applicant have a diagnosis of TPN-associated cholestasis?

No

Yes

If you answered yes, please provide date of onset.

7.) Does the applicant have a diagnosis of TPN – related liver disease?

No

Yes

8.) Does the applicant have a Gastronomy Tube (G-Tube) / PEG Tube?

No

Yes

9.) Has the applicant had a liver biopsy?

No

Yes

If you answered yes, please provide approximate date.

10.) Has the applicant undergone any of the following transplants?

If you answered yes, please provide approximate date.

Please submit a short essay on how immediate assistant from the ZLF will significantly and positively impact the applicant and their family.

Please type City, State you currently reside.

Initials

Today's Date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting to the ZLF Scholarship!!

Zoelle Leaire Foundation does not and shall not discriminate on the basis of race, color, religion (creed), gender, age, national origin (ancestry), disability, marital status or sexual orientation in any of its activities or operations. We are committed to providing an inclusive and welcoming environment for all members of our staff, clients, volunteers, subcontractors, vendors, clients and scholarship recipients.