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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