First Name (required)
Last Name (required)
Middle Initial (required)
Permanent Home Address (required)
Zip Code (required)
Your Email (required)
Age for Academic Year 2021/2022 (required)
Date of Birth:
Who is your doctor?
Your Doctor (required)
Doctor’s Office Address (required)
Academic Institution Information:
Name of College you are/will be Attending (required)
School Address (required)
Main Phone Number:
Name of Highschool (required)
Highschool Address (required)
Highschool Phone Number:
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.
Electronic Signature (required)
Name of Parent or Guardian (if under 18)
Username or email address *
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