Arthritis Foundation, Pacific Region Winterhoff Scholarship
Transcription
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: Must have some form of diagnosed rheumatic disease and have Physician’s Certifying Statement completed and attached. Must be classified as an Undergraduate or Graduate student. 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. 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. 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: 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 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 Page 1 of 4 Effective 01/01/2011 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 Page 2 of 4 Effective 01/01/2011 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. Page 3 of 4 Effective 01/01/2011 Arthritis Foundation, Pacific Region Winterhoff Scholarship Application 2012-2013 Two to three page essay explaining how arthritis has impacted applicant’s life. Page 4 of 4 Effective 01/01/2011