FCCLV SCHOLARSHIP APPLICATION
(Please print out and complete the following application.)
I. PERSONAL DATA:
Name:______________________________________
Address:______________________________________________
City/State/Zip:_________________________________
Summer address: (if different from above)
Address:______________________________________________
City/State/Zip:_________________________________
Daytime Phone: ( _____ ) _____________________
Evening Phone: ( _____ ) _____________________
Male____ Female _____ Date of Birth:_____________
II. VISUAL STATUS:
Check all the methods you use for reading:
( _ ) Braille ( _ ) Recordings ( _ ) Large print ( _ ) Regular print ( _ ) Live reader
III. EDUCATIONAL BACKGROUND:
A) Name and address of school in which you are currently enrolled or last attended:
Name: ________________________________________
Address: _______________________________________________
City/State/Zip: ___________________________________
Cumulative grade point average (based on 4.0 scale): ____________
Major:___________________________________
No. of hours:____________
Degree/Certificate sought: _______________________
Date degree expected: ___________________________
B) School you plan to attend (if different from above)
Name: ________________________________________
Address: ________________________________________________
City/State/Zip: ___________________________________
Major: _____________________________________
No. of hours:_____________
Degree/Certificate sought: __________________________
Date degree expected: ___________________________
C) List any secondary or post-secondary schools which you have attended:
Name of school: ______________________________________
City/State/Zip: ___________________________________
Cumulative grade point average (based on 4.0 scale):____________
Dates attended: From:_________________ To:_________________
Name of school: ______________________________________
City/State/Zip: _________________________________
Cumulative grade point average (based on 4.0 scale): ____________
Dates attended: From:_________________ To:_________________
IV. WORK EXPERIENCE:
Please attach a list of any full-time or part-time work experience you may have. Indicate whether this is summer employment or during
the school year.
V. EXTRACURRICULAR ACTIVITIES:
Please attach a list of any major outside activities (school, church, community, sports, organizations, recreation, etc.). Indicate extent to
which you have acted in a leadership role.
VI. CERTIFICATION OF VISUAL STATUS
To be completed by a physician or agency executive serving people with low or no vision.
This is to certify that the person named on this scholarship application is known to me and is legally blind.
Cause of visual impairment: ___________________________________
Visual Acuity: Right eye: _____ Left eye:____
Name: ________________________________________
Title: _________________________________________
Address: ______________________________________
City/State/Zip: _________________________________
Signature: ____________________________________
Date:____________
Please forward application package to:
Barbara H. Grill
2030 Preymore Street
Osprey, FL 34229
If you have any questions, contact Barbara at (941) 966-7056.
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