The Rick & Amanda Hansen Scholarship for Youth with Disabilities

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Please fill out all sections of the application form below. Fields marked with an asterisk * are required. Where a selection is to be made, please select from the provided options or as instructed. Please keep written answers within the character limits indicated.

1. APPLICATION FORM

a. Personal Information

Legal First Name

Legal Middle Name(s)

Legal Last Name

Preferred Name

Pronouns

Prefer to self-describe

Birthdate

Phone Number

Mailing Street Address

Mailing City

Mailing Province/Territory

Mailing Postal Code(A1AA1A)

b. Academic Institution & Program Information

Current Status:

What is the highest level of education you have completed?

Post-Secondary Program You Will Attend Next Academic Year

Name of Post-Secondary Institution

Street Address of Post-Secondary Institution

City of Post-Secondary Institution

Province of Post-Secondary Institution

Postal Code of Post-Secondary Institution (A1AA1A)

Program Name

Expected Program Start Date

Expected Program Completion Date

Program Duration

Year of Program You Will Enter Next Academic Year

Qualification Earned upon Completion

If other, specify

c. Tuition & Financial Award Information

Expected Annual Tuition Cost * (tuition only; exclude fees, housing, books, supplies)

Have you applied for any other scholarship, award, bursary, grant, or loan?*

Have you accepted any scholarship, award, bursary, grant, or loan?*

If yes – List them and amounts from highest to lowest value (up to 5)

Estimated Annual Budget

Outline your anticipated income and expenses for the upcoming academic year.

Income

Scholarships/Bursaries (excluding this one) ($):

Student loans (if applicable) ($)

Other Income($) (jobs, student loans, family support, etc.):

Expenses

Tuition($)

Mandatory Fees($)

Textbooks and supplies($)

Living expenses (rent, food, etc.)($)

Other expenses (transportation, etc.)

Without this scholarship, are you/your family able to pay for post secondary education without incurring debt?*

d. Describe your achievements demonstrating each of Rick and Amanda Hansen’s three values.

Provide clear, concrete examples of your work, leadership, and impact. Keep responses succinct.

Perseverance. Provide specific examples of overcoming obstacles, your persistence in achieving your goals, or continuous effort despite difficulties. (Maximum 500 characters)

Inclusivity. Tell us about instances where you have promoted understanding, worked to break down barriers for yourself or others, or created an inclusive environment. (Maximum 500 characters)

Being a Difference Maker. Provide specific examples of a time you took initiative, volunteered, or started projects where you have personally contributed to creating positive change. (Maximum 500 characters)

Program Alignment

Explain how your chosen program aligns with your strengths, skills, and academic achievements. (Maximum 750 characters)

Tip: Reference specific courses, projects, leadership roles, and volunteer activities that demonstrate readiness for this field.

Describe how your selected program will support you in achieving your career goals. (Maximum 500 characters)

Tip: Refer to relevant courses, training, placements, co-op/work-integrated learning, labs, or mentorship.

What is your career goal (job title/profession)? (short answer)

What is the NOC code for your desired career goal (job title/profession)? (5 digits)

Financial Need and Impact

Describe how this scholarship will help you overcome financial barriers to pursuing and completing postsecondary education. (Maximum 750 characters)

You may include tuition, books, technology, transportation, housing, and other education related expenses. Focus on factual information related to financial need.

2. DOCUMENT UPLOAD

Upload one combined file that includes, in the following order:

• 1–2-page résumé (no photos permitted),

• Two reference letters (at least 1 from an academic educator, references from family members are not allowed)

• Transcripts for last 2 academic years (copies sufficient)

• Completed Proof of Disability Form

3. REFERENCE DETAILS

Complete these details for the two references that provided your reference letters.

a. Reference # 1 Information

Reference Full Name

Position

Organization

Organization Mailing Address

Primary Phone Number

Number Of Years Known the Applicant

b. Reference # 2 Information

Reference Full Name

Position

Organization

Organization Mailing Address

Primary Phone Number

Number of Years Known the Applicant

4. Additional Questions

Barriers to Post-Secondary Education -Select all that apply. Use ‘shift’ key to select multiple options.

If other barriers, please specify

How did you hear about this scholarship?

If other, please specify

SUBMISSION CHECKLIST

Before submitting, confirm that your package includes:

Completed Eligibility Checklist

Completed Application Form (Sections 1–4)

Résumé (1–2 pages, no photographs)

Two Reference Letters (at least one from an academic educator)

Two Transcripts (most recent two years; copies accepted)

Proof of Disability Form (completed by an authorized medical practitioner)

APPLICATION DECLARATION & AUTHORIZATION

By submitting this application, I:

• Certify that the information provided is accurate and complete to the best of my knowledge;

• Acknowledge that falsified, misleading, or incomplete information may result in disqualification or withdrawal of an award;

• Authorize the Rick Hansen Foundation to verify information provided in this application with relevant organizations, including educational institutions and funding agencies; and

• Agree to the scholarship Terms and Conditions.

I agree to the Applicant Declaration & Authorization.

Full Name (electronic signature):

Date

DEMOGRAPHIC INFORMATION (OPTIONAL)

RHF collects self-reported demographic data to help ensure our programs meet the diverse needs of the disability communities we serve. Responding is optional and will not affect eligibility or selection. Data will be protected in accordance with RHF’s privacy and information security policies.

Do you identify as Indigenous (First Nations, Métis, Inuit)?

Do you identify as female or non binary?

Do you identify as 2SLGBTQ+ and/or sexually diverse?

Do you identify as Racialized (including Black people and People of Colour)?

CONSENT (OPTIONAL)

To help demonstrate the impact of these scholarships, RHF may share information about recipients. Your choices below are optional and will not affect your eligibility or award decision.

I consent to receive updates from the Rick Hansen Foundation School Program.

If I am awarded a scholarship, I give consent to the Rick Hansen Foundation to share my photo and biography on its public facing communications such as its website, newsletter, social channels and annual report.

If I am awarded a scholarship, I give consent to the Rick Hansen Foundation to share my photo and biography in its report to the funder/s who made this scholarship possible.

I consent to be contacted for feedback and/or program evaluation.

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The Rick & Amanda Hansen Scholarship for Youth with Disabilities

ELIGIBILITY CRITERIA