Arthritis Foundation, Pacific Region Winterhoff Scholarship

Arthritis Foundation, Pacific Region
Winterhoff Scholarship Application
2012-2013
Application Deadline: June 1, 2012
Award Amount:
Up to $7,500 each academic year, to be disbursed to student university
accounts at the beginning of the year. The terms established by the donors
require that scholarship funds be utilized only for tuition, books and supplies.
Eligibility:
ƒ Must have some form of diagnosed rheumatic disease and have Physician’s Certifying
Statement completed and attached.
ƒ Must be classified as an Undergraduate or Graduate student.
ƒ Must maintain a minimum 2.5 cumulative grade point average (on a 4.0 scale) in order to be
eligible for renewal for the next academic year.
ƒ Must be enrolled full-time each semester and have completed the full-time units in order to be
eligible for renewal for the next academic year.
ƒ Must be willing to be involved in the Arthritis Foundation Scholarship publicity and agree to
meet with the Arthritis Foundation officials in Phoenix.
Application Process:
ƒ Please complete the information below and mail the completed application and all
attachments to the Northern Arizona University financial aid office at the following address:
Northern Arizona University
Office of Student Financial Aid
Gammage Building 1
P.O. Box 4108
Flagstaff, AZ 86011-4108
ƒ Whether a scholarship will be granted and the amount thereof is within the sole and absolute
discretion of the Arthritis Foundation. There are no guarantees that this scholarship program
will be available in subsequent academic years or that any scholarship will be renewed,
regardless of whether or not the recipient meets the stated qualifications for renewal.
Name
Student ID
Date of Birth
Address
Phone Number
E-mail Address
FAFSA on file
___/___/_____
Yes
Class
Fr Soph Jr Sr Grad Prof
No
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Arthritis Foundation, Pacific Region
Winterhoff Scholarship Application
2012-2013
Release Statement:
I authorize Northern Arizona University to release my academic and financial aid information to
scholarship donors, and it is further understood that any materials submitted for this Application shall
become the property of Northern Arizona University and the Arthritis Foundation.
I understand that this application may also be reviewed by the Arthritis Foundation Board of
Directors and staff.
The federal Family Educational Rights and Privacy Act (FERPA) protects the privacy of educational
records that the university maintains about me. By signing below, I give permission for Northern
Arizona University to disclose to the donor and any review committee the information provided in
connection with this scholarship application for the purpose of the review of my application, and the
administration and promotion of the scholarship program. This may include information from my
educational records, such as my official transcript, letters of recommendation, and financial aid
information. This permission is granted for each semester I am awarded a Winterhoff Scholarship
from the Arthritis Foundation, Pacific Region.
_________________________________________
Signature
_______________
Date
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Arthritis Foundation, Pacific Region
Winterhoff Scholarship Application
2012-2013
Physician’s Certifying Statement:
I verify that _____________________________________ is providing medical
(physician name)
treatment to _____________________________________ who has been diagnosed with
(patient name)
________________________________ which is a form of rheumatic disease. I understand
(diagnosis)
that this information is requested as a component of a scholarship application, provided as the
Arthritis Foundation, Pacific Region’s Winterhoff Scholarship Program. This medical
disclosure will only be utilized as information on this application form and will not be
allowed for any other use. Information regarding treatment and diagnosis will remain subject
to the confidentiality between physician and patient.
Signed
Date
This statement must accompany application.
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Arthritis Foundation, Pacific Region
Winterhoff Scholarship Application
2012-2013
Two to three page essay explaining how arthritis has impacted
applicant’s life.
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