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1. First Name

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2. Last Name

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3. Date of Birth

Date

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4. Gender

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5. Parent/Guardian Name

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6. Parent/Guardian Phone

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7. Parent/Guardian Email

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8. Applicant email

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9. Applicant phone

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10. Mailing Address

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11. High School Name

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12. High School Address

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13. Current Grade Point Average

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14. University/College attending (or planning to attend)

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15. University/College Student ID

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16. Address and Phone # to send the scholarship check. Please check with your school.

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17. The next school year, I will be a:

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18. Will you be an athlete in the NCAA/NAIA during the next school year?

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19. Have you signed an official commitment?

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20. If Yes, what sport will you be playing in?

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21. What organized sports do you currently participate in, and when? (Sport Played, Team Name, Current Competition Level, and Date Played).

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22. List your major athletic achievements in the last 3 years (include competition, team, dates, and results/ranking):

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23. Academic Awards/Honors and Community Service Activity/Awards (Recommendation letters from coaches/teachers are accepted):

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24. What is your latest HbA1c (include the units):

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25. Provide details of any financial support you are receiving from any other organization (including your college/university):

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26. Please write an essay in your words answering the following questions:

Please describe your athletic goals for next three years



Please describe your academic goals:



Please describe your community service activities:



How will this scholarship benefit you?



Why do you believe you are the best candidate for this scholarship?



How many years have you had type 1 diabetes?
What do you remember most from when you were diagnosed with type 1 diabetes?

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