Scholarship Application

Applicant Information:

Title Ms.Mrs.

Home Telephone:

Mobile Phone:

Date of Birth:

Who is your doctor?

Academic Institution Information:

Main Phone Number:

Date Enrolled:

Academic Information:

Highschool Phone Number:

Graduation Date:

Personal Essay:

Please attach a written essay (1,000 word maximum). This essay should highlight:

-Why you will benefit from this scholarship.

-Please share any community service you have participated in.

-Please share how epilepsy has impacted you and the challenges that you have faced.

-Any other information you think might be pertinent.


I certify that the information contained in this application is true.

Date Signed:

Date Signed: