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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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