ILLINOIS ACADEMY OF AUDIOLOGY Au.D. STUDENT SCHOLARSHIP
APPLICATION FORM
Name ______
Last First Middle
Present Address______
Street Address
______
City State Zip
Telephone______Email______
Student ID Number: ______
University Presently Attending ______
Date of Entrance ______Expected Completion Date ______
Are you currently employed? ______If so, where ______
Do you currently have any scholarships or grants? If yes, please describe ______
______
1. Please provide a resume or letter that will help us learn more about your background, including colleges previously attended, graduation date and GPA, present university and GPA, your past and current activities, honors, research, publications, memberships, work and volunteer history, and offices held.
2. Please attach a one to two page essay telling us about yourself. Consider including information about the following: What made you choose the field of audiology? How do you plan to use your degree in audiology? What do you like most about audiology? What special area of interest in audiology do you have? What is your research project? Where do you see yourself in five years?
The recipient of this scholarship award will be required to agree to the following conditions:
1. Join and maintain a Student membership in the ILAA until the student receives the pursued degree,
2. Serve on at least one ILAA committee during the year in which the scholarship is awarded,
3. Attend at least one ILAA Board meetings during the year in which the scholarship is awarded,
4. Willingness to serve as an ILAA Student Board member if so appointed
If you agree with the above requirements for consideration for this scholarship and the information provided in this application is true, please sign and date this form:
Signature ______Date ______
Please return this application and supporting documents to: Gail Gudmundsen, Au.D., ILAA Honors Committee, 61 Martin Lane, Elk Grove Village, IL 60007
ILAA would like to announce the recipients in state and national audiology publications. Please sign the release below if you grant permission to do so. If you would like an article sent to your hometown newspaper, please state the name of the paper and city/state.
I, the undersigned, give permission to the Illinois Academy of Audiology (ILAA) to use my name, likeness, and pertinent information provided in my scholarship application materials in its published materials and news releases (newsletters, newspaper and journal articles, website etc.).
Signature ______Date ______
Newspaper Name and City/State ______