Scholarship Application Foracademic Year 2017-18

Headquarters

1750 Claiborne Ave.

Shreveport, LA71103

318.635.6471

Fax: 318.635.8901

Scholarship Application forAcademic Year 2017-18

Applicant's Full Legal Name:

Name of the high school from which you will graduate:

If you are already enrolled in a college or technical school, what is the name of your college or technical school?

Parish in which Student Resides:

Certification:

By my signature, I certify that the information contained in this scholarship application is true and correct to the best of my knowledge. I further understand that, if awarded, the scholarship may be forfeited should it be determined that false or fraudulent information was provided.

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Student's SignatureDate

Important Dates:

April20, 2017: Application deadline. This is a hard deadline for receipt at Louisiana Association for the Blind. This is NOT a postmark date. Incomplete applications and/or applications received after the deadline will not be considered.

May 12, 2017: The scholarship awardee will be notified. All applicants will be notified about the status of their application.

Mail completed application packet to:Louisiana Association for the Blind

Attn.: Audra M. Hicks

1750 Claiborne Avenue

Shreveport, LA 71103

Scholarship Application

1. Applicant's Full Legal Name:
2. Street or P.O. Box Address:
3. City, State, Zip:
4. Parent/Guardian Name(s), if under 18 years old:
5. High School:
6. Date of Graduation or GED (mm/dd/yyyy):
7. Are you currently attending college or technical school? Yes No
8. If yes, please list school name:
9. Cumulative GPA:
10. SAT/ACT (if applicable):
11. List your School Extra-Curricular Activities and/or Community Service (maximum 2,000 characters):

1. Major or intended field of study:
2. Honors/Awards received (maximum 2,000 characters):

1. Scholastic, professional, or civic societies to which you belong (maximum 2,000 characters):

1. Provide any additional information you believe may help the Scholarship Selection Committee when considering your application (maximum 2,000 characters):

Required Supplemental Materials:

1. On a separate sheet of paper, please describe your educational and career goals (minimum 250 words, maximum 500 words).
2. Attach official transcripts or GED certificate.
3. Attach a copy of the acceptance letter from your chosen accredited college, university, technical or other accredited post-secondary institution.
4. Attach completed eye examination form signed by a physician.
5. Complete release statement authorizing review of eye exam, high school transcripts, and application materials.
6. Please submit at least one letter of recommendation from a current instructor. The statement can be general in nature, but should offer some insight into the applicant's personality, study habits, and attitude.
   

Intended Use of Scholarship Funds

Applicant's Full Legal Name:

The primary purpose of the LAB scholarship is to offset expenses directly associated with tuition, books, assistive devices, and adaptive technologies. In the space below, please submit a budget that outlines your intended use of the scholarship funds, if you are selected as a recipient.

PLEASE NOTE: As a condition of award, scholarship recipients must agree to submit documentationof use of scholarship funds. At the end of each semester or term, the awardee must provide LAB with a report of how funds were used to advance his/her education, including an accounting of funds expended, with supporting documentation (i.e., receipts).

Applicant's Full Legal Name:

Counselor's Certification

By my signature below, I certify the grade point average and test scores reported on this application by the above-referenced student are true and correct.

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SignatureDate

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Printed Name Phone Number

______

Position Email

______

School City

Applicant's Full Legal Name:

Information Release

By my signature, I authorize the LAB Scholarship Selection Committee to review my eye exam, academic transcripts, and application materials.

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Student's SignatureDate

If the applicant is under 18 years old, this form also must be signed by the applicant's parent or guardian:

______

Parent/Guardian SignatureDate

______

Parent/Guardian Printed Name

Mandatory Eye Medical Information

Student's Legal Name:

Student's Address:

Visual Acuity with Best Correction:

Right Eye ______Left Eye ______

Visual Fields (angle of widest diameter of field of vision):

Right Eye ______Left Eye ______

The named individual is being considered for a scholarship for legally blind individuals. Legally blind is defined as "an individual whose central visual acuity does not exceed 20/200 in the better eye with correcting lenses, or whose visual acuity if better than 20/200 is accompanied by a limit to the field of vision in the better eye to such a degree that its widest diameter subtends an angle no greater than 20 degrees."

Based on this definition, the visual function of the named individual is (check one):

______Legally Blind______Not Legally Blind

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Signature of Examining PhysicianDate of Examination

______

Physician's Name PrintedCity

LAB 2017 Scholarship Application FormPage 1 of 6

LAB Form #LVC-1Rev. 01-13-17