|
Epilepsy and Seizure Association of Manitoba Darryl Dacombe Memorial Scholarship Only those students with epilepsy/seizure disorder may apply
Application Form
First Name:______________________ Last Name:_______________________________ Address:_____________________________________________________________________ City/Town:________________________________ Province:_______________________ PostalCode:_______________ Phone Number:_____________________________
Date of Birth (mm/dd/yyyy)_________________________________
Father’s Name:___________________________________________________ Father’s Occupation: ______________________________________________ Mother’s Name:__________________________________________________ Mother’s Occupation:______________________________________________
High School Attended:______________________________________________ Date of Graduation:__________________________________________
Post-Secondary School You will Be Attending: _________________________________________________________________________ Start Date for Post-Secondary: _____________________________________________
Educational and Career Goals: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Community and Extra-Curricular Activities: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
Other Assistance or Scholarships Awarded: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
What Type of Epilepsy Do You Have? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
When Were You Diagnosed? ________________________________________
Other Assistance or Scholarships Applied For: _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
How Did You Find Out About This Scholarship? _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________
**Attach an essay on how epilepsy has affected your life** ( Must be between 1000 and 1500 words)
For scholarship consideration, please forward this application, along with a copy of your most recent academic transcript or marks and two letters of reference to:
Epilepsy and Seizure Association of Manitoba 4 - 1805 Main Street Winnipeg, MB R2V 2A2
Telephone: (204) 783-0466 or toll free 1-866-EPILEPSY Fax: (204) 784-9689 Email: epilepsy.seizures.mb@mts.net
Applications must be received at the office no later than March 31st of the current academic year.
|