Education Enrichment Fund Scholarship Application

Applicant Information

Name*

Address*

City/Region/Locality*

State (Country, if outside the US)*

Zip/Postal Code*

Primary Telephone*

Email Address*

Date of Birth (dd/mm/yyyy)*

Gender Identification
---FemaleMaleTransOtherI prefer not to disclose

Applicant Status*
---Person with epilepsyFamily of person with epilepsyCaretaker of person with epilepsyOther

If not a person with epilepsy, please describe relationship

Institution Information

Name of Institution Attending*

Address

City

State

Zip

Type of School*
---College/UniversityVocational InstitutionTraining CenterOther

If other, please describe:

Course Outcome*
---Degree progressCertificationProfessional knowledgeOther

If other, please describe:

Estimated Course(s) Total Cost (up to $5000.00)*

Financial Rep. Name (Bursar, Treasurer)

Phone

PROFESSIONAL AND EXTRACURRICULAR ACHIEVEMENTSPlease provide answers below that highlight leadership skills, achievements, and experiences, and how they have impacted your directly.

Professional and/or Leadership Skills*

Extracurricular Involvement and/or Accomplishments*

Volunteer Experience and/or Interests*

REQUIRED ESSAY*Please provide an essay (500 words maximum; double-spaced and 12-pt. font) authored by the applicant. The focus of the essay should explain how the applicants’ personal connection to epilepsy has shaped them into the individual they are today AND how this scholarship will ignite them in becoming an “agent of change” in the epilepsy community. Applicants will ideally build upon their responses given in the application and highlight their motivation for seeking to advance their personal knowledge when constructing their essay.

Allowed file types: PDF, DOC, DOCX

ADDITIONAL REQUIREMENTS
Please provide one Letter of Recommendation from an Academic Professional, Community official, or Healthcare Team member of your choice.

A signed letter from a licensed physician verifying whether the scholarship recipient is a patient with epilepsy or a family member and/or caregiver of someone with epilepsy may be requested prior to funds being dispersed. This is not required for initial submission by the applicant and inclusion will not factor into recipient determination.

*Please enter my application in the 2019 CURE Education Enrichment Fund. I understand that the selection of recipients will be at the sole discretion of the Education Enrichment Fund Selection Committee. By signing below, I certify that all information contained in this application is true and accurate, and I authorize CURE to publish, copyright, and use all information contained in this application, including, but not limited to, display on the Internet on any of the CURE websites. I also certify that I am not a CURE or Lundbeck employee or an immediate family member of CURE or Lundbeck and neither I nor my immediate family members directly or indirectly influence the prescribing of epilepsy medications. I authorize the school to share financial information with the CURE Education Enrichment Fund Selection Committee to determine whether I will require the full $5,000 scholarship toward tuition, fees, and books.