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— Female Male Trans* Other I prefer not to disclose
Applicant Status* —Please choose an option— Person with epilepsy Family of person with epilepsy Caretaker of person with epilepsy Other
If not a person with epilepsy, please describe relationship
Name of Institution Attending*
Address
City
State —Please choose an option—
Zip
Type of School* —Please choose an option— College/University Vocational Institution Training Center Other
If other, please describe:
Course Outcome* —Please choose an option— Degree progress Certification Professional knowledge Other
If other, please describe:
Estimated Course(s) Total Cost (up to $5000.00)* Financial Rep. Name (Bursar, Treasurer)
Phone
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. Applicant responses:
Identify up to three accomplishments you are most proud of and briefly explain why: 0 / 750
Provide up to three examples demonstrating your passion to help others in the community: 0 / 750
Describe a situation (academic, social, work, etc.) in which your leadership made a difference: 0 / 750
REQUIRED ESSAY* Please provide an essay (500 words maximum; double-spaced) 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
*Please enter my application in the 2021 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.
