Teresa Haven Scholarship for Students with Disabilities Application-Nominee

Application Form-To Be Completed By The Applicant

Submit applications by April 21, 2023. Incomplete applications will not be considered. After submitting this form please email your transcripts and letters of support to scholarship@athenpro.org.

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* 1. Name:

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* 2. Address:

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* 3. Phone:

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* 4. Email:

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* 5. Disability (Optional):

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* 6. Year of graduation from high school (if less than 5 years ago):

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* 7. Are you currently registered at a postsecondary institution in the United States?

Yes

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* 8. If yes, please specify:

Quarter/Semester and Year of Admission (ex: Fall 2023)

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* 9. If you have been admitted but are not currently registered at a postsecondary institution in the United States please indicate when you plan to register.

Quarter/Semester and Year of Expected Registration (ex: Fall 2023)

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* 10. Identify postsecondary institutions in the United States, with majors and minors you are pursuing.

Institution 1, Major/Minor

Institution 2, Major/Minor

Institution 3, Major/Minor

Institution 4, Major/Minor

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* 11. In chronological order of attendance, list all formal education after high school, including all colleges and universities, technical training, other comparable academic education. For all institutions listed below, please email transcripts to scholarship@athenpro.org. Unofficial transcripts that are issued free of charge are acceptable.

Institution 1/Dates Attended

Institution 2/Dates Attended

Institution 3/Dates Attended

Institution 4/Dates Attended

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* 12. Give an overview of your educational pursuits and goals. If you have aspirations for future academic study or for a specific career, discuss your plans. (Please limit your response to 1,000 words or less. You may wish to copy and paste your response from a text editor.)

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* 13. Describe your past formal and informal experience, including work, community or student activities and leadership positions. (Please limit your response to 1,000 words or less. You may wish to copy and paste your response from a text editor.)

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* 14. Two Letters of Support (Please check the box to confirm that you have read and agree to the following statement.)

I understand that in addition to a letter of support from the ATHEN/AHEAD nominator, I am required to ask one person to write a letter of support for my application. (Note to applicant: It may be helpful to your references if you provide them with a copy of your personal statement.) Letters of support must be emailed by author of the letter to scholarship@athenpro.org by April 21. My application will not be forwarded to the Selection Committee without letters of support.

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* 15. Please list the name and contact information for the individual (other than the ATHEN member) you’ve asked to write a letter of support for this scholarship.

Name:

Contact Information: