General Information
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| Name: |
| Date: |
| Present Phone: ( ) |
| Permanent Phone: ( ) |
| Present Address: |
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| Permanent Address: |
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| Place of Birth (City, State): |
| Marital Status: |
| Number of Dependents: |
| Current Class Status (circle one): HS Student FR SO JR SR GRAD Unclassified |
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Educational Information
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| High School |
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Name of School:
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Location of School:
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Date of Graduation:
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Class Rank:
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| If applicant is a HS Senior |
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Which academic program have you been accepted into?
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Circle One: Full-time Part-time
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Planned Completion Date:
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| College (List all colleges / universities addtended): |
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Name of School Attended:
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City, State:
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Years:
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Degree Received?
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Name of School Attended:
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City, State:
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Years:
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Degree Received?
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Name of School Attended:
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City, State:
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Years:
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Degree Received?
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Financial Information
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| 1. Please describe your expected educational expenses: |
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| 2. Itemize your DISABILITY-RELATED EXPENSES (medication, wheelchair, tutoring, attendant care, equipment, etc.) NOT covered by other sources (such as Vocational Rehabilitation, ALTCS, ICA, VA, etc.). Use the back of this form if you need more space. |
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Type of Expense
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Cost / Semester
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$ |
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$ |
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$ |
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| 3. What other financial assistance have you applied for? Indicate the status of those applications. |
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Funding Possibilities / Scholarship Applications:
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Status of Application:
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| 4. What sources of financial assistance will you draw on to support your education? |
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Source (i.e. parents, etc.)
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Amount Expected:
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$ |
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$ |
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$ |
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Supplemental Information
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| 1. Itemize any honors, awards or nominations for awards that you have received: |
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| 2. List any organizational affiliations or extracurricluar activities you are involved in: |
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