SCHOLARSHIP APPLICATION

We are excited to learn more about you and your goals to advance your education! Fill out your application below and be sure to read all the instructions carefully.

Which Scholarship Are You Applying For?

Please select the correct scholarship to which your are submitting your application. If submitting to both, please do so separately and indicate here which.

Applicant Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone #

(###)

###

####

Date of Birth

YYYY

Current Epilepsy Physician

First Name

Last Name

Office Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician's Phone #

(###)

###

####

Name of Current/Last School Attended

Graduation Date

YYYY

Address of School

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

High School GPA (4.0 Scale)

SAT Score

Leave blank if you wish to use ACT score

ACT Score

Leave blank if you wish to use SAT score

Please List Honors / Achievements / Extra Curricular Activities

Future Institution - Name of college/vocational school you plan on attending or are enrolled

Student ID #

(If you have one already, if not leave blank)

Address of Future Institution

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Degree/Area of Study Being Pursued

Name of Applicant/Guardian

The Central Florida Epilepsy Scholarship Foundation may at their discretion conduct interviews in person with finalists for awards. If you agree to an interview please sign and check below to indicate your acceptance:

First Name

Last Name

Date

YYYY

Student agrees to an interview if requested:

Decline