Applicant Information:

Title Ms.Mrs.

First Name (required)

Last Name (required)

Middle Initial (required)

Permanent Home Address (required)

City (required)

State (required)

Zip Code (required)

Home Telephone:

Mobile Phone:

Your Email (required)

Age for Academic Year 2021/2022 (required)

Date of Birth:

Sex (required)

Who is your doctor?

Your Doctor (required)

Doctor’s Office Address (required)

City (required)

State (required)

Zip Code (required)

Academic Institution Information:

Name of College you are/will be Attending (required)

School Address (required)

City (required)

State (required)

Zip Code (required)

Main Phone Number:

Date Enrolled:

Academic Information:

Name of Highschool (required)

Highschool Address (required)

City (required)

State (required)

Zip Code (required)

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.

Certification:

I certify that the information contained in this application is true.
Electronic Signature (required)

Date Signed:

Name of Parent or Guardian (if under 18)

Date Signed: