2022 Scholarship Application - Epilepsy Foundation of Minnesota

Part 1: Applicant Information

First Name

Last Name

Email

Phone

Street Address

City

State

Zip Code

Date of Birth:

Are you diagnosed with epilepsy?

STOP! By selecting "No," you do not qualify for this scholarship.

EFMN is asking demographic questions to have a better understanding on who we serve. Although all questions are required, there is always a "Prefer not to answer" option if you choose to keep this information private. The options for demographic questions are in accordance to the US Census Bureau.

Gender

Race

Ethnicity

Academic Information

What type of student are you currently?

High School StudentCollege Student

High School Information

School Name

School Street Address

School City

School State

School Zip Code

Graduation Date (actual or expected)

Current GPA

Please list any academic or school awards that you have received, and/or other school :

Post Secondary Information

Have you been accepted to a post secondary institution?

YesNo

STOP! By selecting "No," you do not qualify for this scholarship.

To which universities, colleges, and/or vocational school have you accepted?

Submit a copy of your acceptance letter or confirmation of enrollment:

What would you like to major in? (If unsure, please write in Undecided.)

College Information

School Name

School Street Address

School City

State

School Zip Code

Graduation Date (actual or expected)

Current GPA

Major (If unsure, please type in Undecided.)

Submit a confirmation of enrollment:

Most institutions have an enrollment verification form that can be requested or downloaded. A copy of class schedule or transcript is also acceptable.

Please list any academic or school awards that you have received:

Getting to Know You

Questions

In short paragraphs, please answer the questions below.

What are your career/future goals?

Tell us about your journey with epilepsy. How have you addressed any obstacles that you have faced?

What is your involvement with the community and/or with the Epilepsy Foundation of Minnesota?

Tell us about a moment that you felt most accomplished or feel most proud of.

Additional Enclosures

Submit ONE letter of recommendation.

Ideas for recommenders include: a physician, teacher, academic adviser, principal, coach, etc.

Letters may be:

uploaded below, *
emailed to Mary Meuwissen at mmeuwissen@efmn.org, **
or mailed to Mary Meuwissen at 1600 University Ave W, Ste 300, St. Paul, MN 55104. **

* Uploaded documents must be submitted as PDF documents

** Letters of recommendations emailed or mailed must be received by May 20, 2022

Recommendation 1

Full Name

Relationship

Letter format:

Upload Letter of Recommendation

I hereby certify that the facts presented in the above application are true and complete to the best of my knowledge. I understand that completing this application does not ensure a scholarship award and that my application will be reviewed by members of the review committee, therefore not guaranteeing confidentiality.

Please read and check the boxes below:

I grant permission for the Epilepsy Foundation of Minnesota to use my name and photo.

If selected for the scholarship, I agree to write a Thank You letter/note to the donor(s).

Scholarship recipients may be asked to attend an in-person gathering with members of the EFMN Board of Directors and supporters.

Electronic Signature

Date

Baer and Clay Scholarship Application

Part 1: Applicant Information

Academic Information

Getting to Know You