Microsoft word - anne ford scholarship application 2009-10.doc

The Anne Ford and Allegra Ford Scholarship 2009-2010
National Center for Learning Disabilities, Inc.
Deadline for Submission:
The Anne Ford and Allegra Ford Scholarship is a $10,000 award given to two high school
seniors with identified learning disabilities (LD) who will be pursuing four-year
undergraduate degrees.

Eligibility and Selection Criteria
The National Center for Learning Disabilities, Inc. (NCLD) is seeking applicants for the Anne Ford and Allegra
Ford Scholarship, which is available to students of high merit with an identified learning disability (LD). To be eligible for the Anne Ford and Allegra Ford Scholarship, an applicant must: • Have an overall grade point average (GPA) of 3.0 or higher on a 4 point scale (or equivalent) • Provide most current documentation of an identified learning disability Note: ADD/ADHD or Asperger’s alone is not considered a learning disability; eligible candidates with ADD/ADHD or Asperger’s must also provide documentation of a specific learning disability • Be enrolled as a senior in high school, public or private, with the intention of pursuing a 4-year Students of minority background are encouraged to apply.
The Ideal Anne Ford and Allegra Ford Scholar
The ideal candidate is a high school senior who: • can articulate his/her learning disability, understands how LD affects his/her life, and recognizes the • is committed to completing a four-year college degree and has begun to set realistic career goals; • has demonstrated perseverance and embraces new opportunities; • has a well-rounded perspective shaped by experiences in school, in the community, and with family • believes in contributing to society in ways that increase the opportunities for individuals with learning • will feel comfortable serving as a role model and spokesperson for others who struggle with LD.
Mentoring and Outreach Opportunities
The Anne Ford and Allegra Ford Scholar must be willing to mentor future Scholars and act as a role model for individuals with LD through such activities as public speaking, writing for publications, and engaging in other opportunities made possible through NCLD.
Application Requirements
Scholarship applicants must submit the following materials in one packet in order to be considered for the
A personal statement, describing the applicant’s frustrations and triumphs in dealing with his or her specific learning disability. Applicants should feel free to express themselves in creative ways, and be sure to share how they embody the characteristics of an ideal candidate (as described above). The statement should make specific mention of how he/she believes a college education will enhance his/her life. (This may be submitted as a written essay of 750-1000 words or a video/audio tape no longer than 15 minutes in length. Tapes should be accompanied by a written script and/or outline and must be clearly A high school transcript. Applicants should contact their school guidance office or the appropriate school administrator to obtain a copy (unofficial transcripts will be accepted). Instructions: Each letter of recommendation must be attached to a copy of the Letter of Recommendation Form (found on page 6), and each must be enclosed in a separate sealed envelope and included in the complete application packet. At least one letter should come from a teacher, past or A financial statement (see page 7 of application). Standardized test scores (SAT, ACT, other). Unofficial copies of standardized test score reports will be Current documentation of a learning disability that includes evaluation reports, I.E.P. and/or 504 plan, etc. (Applicants should note that ADD/ADHD alone is not considered a learning disability. Eligible candidates with ADD/ADHD must also provide documentation of a specific learning disability). All application materials must be submitted in one packet.

Selection Process
The Anne Ford and Allegra Ford Scholarship Committee, comprised of members of NCLD’s Board of Directors, Professional Advisory Board and distinguished friends, will make the final selection in Spring 2010.
Scholarship Requirements
Anne Ford and Allegra Ford Scholars are required to submit annual updates detailing their progress in school and offering insight about their academic and personal growth. The $10,000 scholarship will be paid in four yearly installments of $2,500. Scholars must submit proof of course registration to receive their first installment. To continue receiving payments, scholars must provide proof of course registration for each ensuing semester and documentation of passing grades (transcripts). A completed application packet (including ALL application materials) should be sent to:
Anne Ford and Allegra Ford Scholarship
National Center for Learning Disabilities, Inc. For further information contact: [email protected] Please note: Any materials submitted as part of the application process will not be returned.
The Anne Ford and Allegra Ford Scholarship 2009-2010
National Center for Learning Disabilities, Inc.
Checklist
Use this checklist to keep track of the items you need for your Anne Ford and Allegra Ford Scholarship application:
APPLICATION REQUIREMENTS

Personal Statement – either written essay or video/audio tape and transcript High school transcript (official or unofficial). Three (3) letters of recommendation (at least one from a teacher). Financial statement (see page 7 of application). Standardized test scores (SAT, ACT, other). Unofficial copies are acceptable. Most recent documentation of a learning disability. All application items must be postmarked no later than December 31, 2009
Incomplete or late application packets will not be reviewed.
All application materials must be submitted in one packet.
The Anne Ford and Allegra Ford Scholarship 2009-2010
National Center for Learning Disabilities, Inc.
Application
Completed application packet must be postmarked no later than December 31, 2009
APPLICANT INFORMATION
Name:
Date of Birth: / / check one: □ male □ female (month) (day) (year)
Social Security Number: - -
Mailing Address:
Home phone: ( ) - Cell phone: ( ) -
U.S. citizen* □ Yes □ No E-mail:
*Applicants must be current US citizens. If you have questions about your eligibility for this award, send your inquiry to
AFScholarship @ncld.org
PARENT/GUARDIAN INFORMATION
Name(s) :
Mailing Address (if different than above):
Check all that apply: □ parent □ legal guardian

□ other relative (specify)____________ □ other (specify)_____________

Home phone (if different than above): ( ) - Cell phone: ( ) -
Email:
SCHOOL HISTORY
High School(s):

Middle School(s):
Name

Primary School(s):


Grade point average (GPA) _____________ (as per current high school transcript)
Extracurricular Activities:*

Community Activities and/or Work Experience:*
Hobbies/Skills:*

(*Attach separate page if necessary)
Please indicate your specific learning disability (check all that apply):
Other (please describe in your own words): Math ____________________________________________________________ Written expression ____________________________________________________________ Spelling ____________________________________________________________ Date of initial diagnosis/classification: _____________________

Date of most recent testing: _______________________________

How did you hear about the Anne Ford and Allegra Ford Scholarship?

CERTIFICATION AND AUTHORIZATION
Certification: All of the information provided on this form is true and complete to the best of my knowledge. I certify that
I have a documented learning disability, will be earning my high school diploma or its equivalent, and will be enrolling for
the first time in a full-time college program in the 2009-2010 academic year. I hereby authorize the National Center for
Learning Disabilities, Inc. (NCLD) to use excerpts from my essay along with non-financial information from my application
for publicity and public relations purposes, provided that my confidentiality is protected. I understand that information
contained in my essay may be used for research and/or publicity related activities. All application materials including essays
and transcripts become property of NCLD.

Authorization for Release of Information/Records: Applicants are responsible to arrange for transcripts and other
required documentation to be submitted to NCLD. In the event that NCLD finds it necessary to seek additional information,
permission is hereby given to NCLD and its designees to contact school officials and others to request additional relevant
information for use by the Anne Ford and Allegra Ford Scholarship Selection Committee and/or NCLD staff.
Signature of Applicant______________________________________ Date _______________________
Signature of Parent or Guardian_______________________________ Date _______________________
The Anne Ford and Allegra Ford Scholarship 2009-2010
National Center for Learning Disabilities, Inc.
Letter of Recommendation Form
All applications must be postmarked no later than December 31, 2009
Please attach this form to your written recommendation and return it to the student so it can be
included in the completed application packet.

Name of Applicant: _______________________ Date of Birth: ____ /____ /_____

Description of Anne Ford and Allegra Ford Scholarship
The Anne Ford and Allegra Ford Scholarship is a $10,000 award to two high school seniors with identified
learning disabilities (LD) who will be pursuing an undergraduate degree.

The Ideal Anne Ford and Allegra Ford Scholar
The ideal candidate is a high school senior who has faced the challenges of having a learning disability; is committed to completing a college degree and setting career goals; has demonstrated perseverance; embraces new opportunities; has a well-rounded perspective shaped by experiences in school, in the community, and with family and friends; understands how LD affects his/her life and recognizes the importance of self-advocacy; believes in contributing to society in ways that increase the opportunities and potential of ALL people with learning disabilities; and will feel comfortable serving as a role model and spokesperson for others who struggle with LD.

INSTRUCTIONS
Please provide the following information:

Name: Title:
School/Organization:
Address:
Telephone: ( ) - ext. e-mail:
How do you know the applicant?
How long have you known the applicant?


On a separate sheet of paper or letterhead, please explain why you are recommending the applicant for the
Anne Ford and Allegra Ford Scholarship. Please use the above description to guide your comments. It would be helpful to have you reflect upon the applicant’s understanding of his/her LD, ability to self-advocate, academic ability, tenacity/perseverance, involvement in school and community activities, leadership, and future plans.

For more information about the National Center for Learning Disabilities or the Anne Ford and Allegra Ford
The Anne Ford and Allegra Ford Scholarship 2009-2010
National Center for Learning Disabilities, Inc.
Financial Statement
To be filled out by the applicant’s parent(s) or legal guardian Completed application packet must be postmarked no later than December 31, 2009
Name of Applicant: _______________________ Date of Birth: ____ /____ /_____

STATEMENT OF INCOME (please select an option below)
Option 1

Total income as reported on household’s (applicant and parent/guardian) most recent federal income tax return: $ ____________________
Total number of exemptions claimed: ____ $____________________
$____________________
$____________________
$____________________

List all members of household, ages, and relationship to applicant:
Is this a single parent family?
( ) Yes ( ) No

Number of dependent children in the family:
_____________________

Number of dependent children currently attending college:
_____________________
Planned year(s) of graduation:
_____________________
Number of dependent children currently attending high school: _____________________
Planned year (s) of graduation:
_____________________
COLLEGE INFORMATION
Names of colleges
to which applicant applied
Accepted
(circle one)
Expected Tuition Costs
______________________________
Y pending
$_____________________
______________________________
Y pending
$_____________________
______________________________
Y pending
$_____________________
______________________________
Y pending
$_____________________
______________________________
Y pending
$_____________________
______________________________
Y pending
$_____________________
Those candidates chosen for final review by the Selection Committee will be asked to submit copies of the most recent household federal income tax returns and W-2 forms. Please attach any additional information that you would like to share regarding your financial situation.

Source: http://www.sst5.k12.oh.us/ford_scholarship.pdf