industriousness Form for the Stephen A. Segar College Scholarship
For exalted school seniors and current college students who slang epilepsy and who live in the 22 counties served by the Epilepsy stern of Rochester-Syracuse-Binghamton in upstate New York. Three winners will be chosen.
Application deadline: April 30, 2012
Part 1: GENERAL INFORMATION
learn:____________________________________________________ Age: _______ manlike or Female: _________ Address: ____________________________________City: _________________ State: ________ ZIP: ___________ band: ________________________________ E-mail _____________________________________________ How did year hear about this light weapons platform? ___________________________________________________ At what age were you diagnosed with epilepsy? ______ Are you seeing a heal for epilepsy?_______ Are you taking medicine for your seizures at this time? _______ Name of recommending doctor: ____________________________________________________________
_______ Address: ___________________________________________ City: ______________ State: ____ ZIP: __________ Do you authorize your doctor to release information about you for this scholarship platform?
_______________ Your Signature: ________________________________________________ Date: ___________________________ Do you authorize the Epilepsy Foundation of Rochester-Syracuse-Binghmaton to release information about you for promotional purposed for this scholarship program? _______________ Your Signature: ________________________________________________ Date: ___________________________ Name of school:_______________________________________ Expected start date:___________________ Address: ____________________________________________________________
____________________________ Colleges or schools to which you have applied (for high school applicants):_______________________________
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