Education Enrichment Fund Scholarship Application

Applicant Information

Full Name*

Address*

City/Region/Locality*

State (Country, if outside the US)*

Zip/Postal Code (if applicable)

Primary Telephone*

Email Address*

Date of Birth (dd/mm/yyyy)*

Gender Identification
—Please choose an option—FemaleMaleTrans*OtherI prefer not to disclose

Applicant Status*
—Please choose an option—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
—Please choose an option—

Zip

Type of School*
—Please choose an option—College/UniversityVocational InstitutionTraining CenterOther

If other, please describe:

Course Outcome*
—Please choose an option—Degree progressCertificationProfessional knowledgeOther

If other, please describe:

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

Financial Rep. Name (Bursar, Treasurer)

Phone

LEADERSHIP AND COMMUNITY INVOLVEMENT

Please provide responses below highlighting your leadership skills, achievements, honors, community activities, and experiences. These answers are meant to provide CURE Epilepsy and the scholarship selection committee with insight into you. Your answers can reinforce information in your essay but should not restate it. Your answers do not have to relate to epilepsy. Applicant responses are maximum of 750 characters per field and should be listed in bullet point form.

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 applicant's 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 highlight their motivation for seeking to advance their personal knowledge when constructing their essay.

Allowed file types: PDF, DOC, DOCX

RECIPIENT REQUIREMENTS

*not required for application submission

This section is ONLY applicable to those selected to receive the Education Enrichment Fund Scholarships and are not required for initial submission by the applicant. Inclusion will not factor into recipient determination but may be submitted at the time of application.

• A photograph of the scholar is required upon return of the Scholarship Award Agreement. Photograph size and resolution details will be provided in the Agreement.

• 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 required prior to funds being dispersed.

*Please enter my application in the 2020 CURE Epilepsy 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 Epilepsy 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 Epilepsy websites. I also certify that I am not a CURE Epilepsy or Greenwich Biosciences employee or an immediate family member of CURE Epilepsy or Greenwich Biosciences 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 Epilepsy Education Enrichment Fund Selection Committee to determine whether I will require the full $5,000 scholarship toward tuition, fees, and books.