ERIC BURTON OSBERG

SCHOLARSHIP

(Please print or type)*

PART 1: GENERAL INFORMATION

Name:______Age:______Male Female

Address:______City:______State:_____ Zip:_____

Telephone:______Email: ______

How did you hear about this program? ______

At what age were you diagnosed with epilepsy? ______

Are you seeing a neurologist for epilepsy at this time? yes no Date of last visit_____/_____/_____

Are you taking medicine for your epilepsy/seizures? yes no

Are your seizures currently controlled? yes no

Name of recommending doctor:______

Address:______City:______State:_____ Zip:______

Phone:______

Name of high school:______(Expected) graduation date:______

Address of high school:______

Schools to which you have applied:______

PART 2: ACADEMIC RECORD

List any honors or accomplishments you have earned in school:______

______

PART 3: ACTIVITIES OUTSIDE OF SCHOOL

List any activities you have been involved in outside of school:______

______

PART 4: SHORT PERSONAL STATEMENT

Write a brief essay (500 word minimum) about something you have dealt with as a person with epilepsy. You may discuss one of these topics or use one of your own:

  • How you have overcome the challenges of epilepsy (personally, socially, in school, elsewhere)?
  • What does having epilepsy means to you?
  • Someone who has been helpful to you in your success (include how)
  • An achievement of which you are proud.

If writing isn’t your strong suit, you may schedule an in person interview with the committee, produce a short video, or find another way to show the committee who you are.

PART 5: OTHER ITEMS TO ENCLOSE

Please send these items with this form:

 A letter from the your neurologist confirming that you are a current patient and are receiving treatment for epilepsy/seizure disorder.

 A copy of your current technical, culinary, trades and/or computer school acceptance letter, current academic transcript, or a letter discussing your intention of applying.

 A written statement (500 word minimum). This written statement should address your academic goals, demonstrate need of scholarship, and describe how epilepsy has affected your life and academics. See Part 4 above for further information.

 One letter of recommendation written by someone who is not a family member. The letter of recommendation should address the your academic potential as well as your potential to serve as a positive ambassador for the EFEPA.

Please return this form (with the items listed above) to:

Epilepsy Foundation Eastern Pennsylvania

Attn: Scholarship review Committee

919 Walnut Street, Suite 700

Philadelphia, PA 19107

Or fax the documents to: (215) 629-4997 and list “Attn: Scholarship Review Committee” on the cover sheet