Ryan Nicolaisen Memorial Scholarship

Section 1: Applicant Information

Data Privacy Notice

Your privacy is important to us. Information collected through this form is used solely for managing educational assistance. Data will not be shared with third parties without your written consent.

Full Name *

Date Of Birth *

Address *

City / State *

Zip Code *

Phone Number *

Email Address *

Patient Verification *

I acknowledge that I have read the Data Privacy Notice and consent to the processing of my data. *

Section 2: Medical Eligibility

Strict Medical Requirement Notice

Applicants MUST have a diagnosed rare bleeding disorder to be eligible. All health-related data is treated as Protected Health Information (PHI).

Diagnosed Rare Bleeding or Qualifying Condition *

Section 3: Program & School Details

Type of Assistance Requested *

Academic ScholarshipVocational TrainingProfessional Certification ExamExtracurricular / Development Programs

Name of School / Program / Organization *

School Email Address *

School Contact Number *

School Street Address *

School City / State *

School Zip Code *

Program Start and End Date

Amount Requested (Include Currency) *

Section 4: Statement of Purpose

What are your Educational or Vocational goals? *

How will this assistance support your personal growth, independence, and long-term stability? *

How do you plan to use this opportunity to positively impact your community? *

Section 5: Budget Breakdown

Itemize how the funds will be allocated. Include local currency indicators.

Tuition / Fees *

Books / Materials *

Technology / Tools *

Certification / Exam Fees *

Others (Please specify expenses)

Total Amount Requested *

Section 6: Certification & Signatures

I certify that: All information provided is accurate; funds will be used exclusively for approved education lanes; and I acknowledge that submission does not guarantee selection approval. *

Printed Name *

Signature (TYPE INITIALS) *

Date *

Section 7: Supporting Documentation

Important Application Notes

Strictly Required: All uploaded proofs must be recent and current.
Processing Time: Please allow 3 weeks to 1 month.
Communication: We may request additional documents during review.

Upload files to ImgBB.com or a secure cloud link, then paste the URL below. Or email files to info@freebleeders.org.

Proof of Rare Bleeding Disorder (Strictly Required: Proof must be less than 3 months old)

Copy of Bill / Invoice Link (Strictly Required: Must be recent and current)

Proof of Enrollment or Activity Link

The Ryan Nicolaisen
Memorial Scholarship

About This Scholarship

This Scholarship Honors:

Eligibility Requirements

Free Bleeders Inc.