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Post-Secondary Bursary Application
Name of Applicant
Date of Birth (MM/DD/YYYY):
Address:
City: Province: Postal Code:
Telephone: Home: Cell: Work:
Email:
Type of bowel or bladder diversion (Please note this must be a permanent condition):
Name of Post-Secondary Educational Institution Planning to Attend: (**Note this must be within Canada)
You will require two (2) References: (**Must be other than a family member)
Reference #1:
Name: Telephone: Rel ationship:
Reference #2:
Name: Telephone: Rel ationship:


Please refer to the Bursary Criteria for more informaton:
Applicaton deadline: It is the responsibility of the applicant to ensure that all relevant informaton is
received by November 1, 2014
Please send completed applicaton forms to:
United Ostomy Associaton of Canada
Atenton: Bursary Commitee
344 Bloor St. West, Suite 501
Toronto, ON M5S 3A7

This application is to assist individuals living with a permanent ostomy or other bowel or blad-
der diversionary surgery to pursue post-secondary education.
________________________________________________________
Signature
_________________
Date
ESSAY: In 500 words, please explain your objectives in receiving a grant from the United Ostomy
Association of Canada