Anne Ford Scholarship 20122013 1zz4n

The Anne Ford Scholarship

Use this scholarship application only if: -

You are a graduating high school senior (Class of 2013)

-

You have a documented learning disability

-

You are planning to attend a 4 year college or university starting in the Fall of 2013

1

2012-2013 Application Information

The National Center for Learning Disabilities is seeking applicants for the 2012-2013 Anne Ford Scholarship. The Anne Ford Scholarship is a $10,000 ($2,500/year over four years) award granted to a graduating high school senior with a documented learning disability who will be enrolled, in the fall of 2012, in a full-time bachelor’s degree program. The ideal Anne Ford Scholar is a student who: • Articulates his/her LD and clearly demonstrates the importance of self-advocacy • Is committed to completing a four-year college degree and has begun to set realistic career goals • Plans to contribute to society in ways that increase opportunities for individuals with LD • Excels as a role model and spokesperson for others who struggle with LD • Demonstrates financial need

Eligibility & Selection Criteria To be eligible for the 2012-2013 Anne Ford Scholarship, an applicant must: • Have an overall Grade Point Average (GPA) of 3.0 or higher on a 4 point scale (or equivalent) • Demonstrate financial need • Provide most current documentation of an identified learning disability (Please Note: AD/HD alone is not considered a learning disability; eligible candidates must also provide documentation of a specific learning disability.) • Be a U.S. citizen Please Note: If you will be attending a two-year community college, vocational or technical training program, or specialized program for students with LD, you are not eligible for the Anne Ford Scholarship. Please visit our website at www.LD.org for more information on the Allegra Ford Thomas Scholarship. You may not apply to both scholarships.

Mentoring & Outreach Opportunities The Anne Ford Scholar must be willing to mentor future Scholars and act as a role model for individuals with learning disabilities through such activities as public speaking, writing for publications, and engaging in other opportunities made possible through NCLD.

Scholarship Requirements Scholars are required to submit annual updates detailing their progress in school and offering insights about their academic and personal growth. The $10,000 scholarship will be paid in four yearly installments of $2,500. Scholars must first 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 ing grades (transcripts).

Selection Process The Anne Ford Scholarship Committee, comprised of of NCLD’s Board of Directors, Professional Advisory Board, and distinguished friends, will make the final selection of scholars in Spring 2013.

Submitting Your Application Please use the Application Requirements Checklist to make sure that all needed materials are included in the scholarship packet. All required materials must be received in one packet.

Questions? First, please check out the Frequently Asked Questions on our website. If your question is not answered there, you may us. Email: [email protected] Phone: (888) 575-7373

2

Application Requirements Checklist

The Anne Ford Scholarship is for graduating high school seniors who will be attending a four-year, bachelor’s degree

program in the fall. If you are planning to attend community college, vocational or technical school, or a specialized program for students with LD, please visit us at www.LD.org to apply for the Allegra Ford Thomas Scholarship.

Do not apply to both the Anne Ford Scholarship and the Allegra Ford Thomas Scholarship.

Use this checklist to keep track of items needed for the Anne Ford Scholarship Application.

Please be sure that you return the following items in your packet:  Basic Information Form

 Personal Achievements & Activities Form

 A personal statement (see “Personal Statement” page for details)  High school transcript (official or unofficial)

 Three (3) letters of recommendation (at least one from a teacher)

 Financial Statement Form

 SAT, ACT, or other standardized test scores (unofficial copies acceptable)  Most recent documentation of a learning disability

Submit all of these materials IN ONE PACKET to:

National Center for Learning Disabilities c/o Anne Ford Scholarship

381 Park Avenue South, Suite 1401 New York, NY 10016

Applications MUST be postmarked by December 31, 2012. Please note that any materials submitted as part of the application process will not be returned.

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Basic Information Form

Please write legibly or type in your answers.

APPLICANT INFORMATION

PARENT/GUARDIAN INFORMATION

Applicant Name:

Parent/Guardian Name(s): Last

Date of Birth:

Month

First /

Middle /

Day

Year

Mailing Address: City:

Mailing Address (if different from applicant): City:

State:

Home Phone:

Zip Code: Cell Phone:

Applicant Email Address (Use block letters):

State:

Zip Code:

Parent/Guardian Home Phone (if different from applicant): Parent/Guardian Cell Phone: Parent/Guardian Email Address (Use block letters):

 @.

 @.

 Yes, I would like to subscribe to NCLD email updates, newsletters, and alerts.

 Yes, I would like to subscribe to NCLD email updates, newsletters, and alerts.

Are you a United States Citizen?*

What is your relationship to the applicant? (Check all that apply)

 Yes

 No

*Applicants must be current U.S. citizens. If you have questions about your eligibility for this award, send your inquiry to [email protected].

 Parent

 Legal Guardian

 Other Relative (specify): _____________

 Other (specify): __________________

SCHOOL HISTORY High School(s): Name of School

City/State

Years Attended

City/State

Years Attended

City/State

Years Attended

Middle School (s): Name of School

Primary/Elementary School(s): Name of School

How did you hear about the Anne Ford Scholarship?

 Family

 School

 Website (please specify): ____________________

 Other (please explain): __________________________________________________________

LEARNING DISABILITY INFORMATION Please check which of these learning disabilities you have.  Basic Reading Skills (Dyslexia)

 Reading Fluency Skills (Dyslexia)

 Spelling

 Reading Comprehension (Dyslexia)

 Listening Comprehension (and processing)

 Written Expression (Dysgraphia)

 Math Calculation (Dyscalculia)

 Math Problem Solving (Dyscalculia)

Date of Initial Diagnosis/Classification: ________________________________

 Executive Functioning/Organization Skills

 Non-verbal LD

 Other (please explain):

______________________________________

Date of Most Recent Testing: __________________________________

(Please Note: In order to be eligible for the Anne Ford Scholarship, applicants must have documentation of a specific learning disability, such as dyslexia, dyscalculia,

dysgraphia, etc. Conditions including AD/HD, Asperger’s Syndrome and other autism spectrum disorders, Cerebral Palsy, and psychiatric conditions do not alone qualify a

student for this scholarship. Applicants with these conditions are welcome to apply but must also provide documentation of a specific learning disability.)

OPTIONAL SELF-IDENTIFICATION  African-American/Black (not of Hispanic origin)

 American Indian or Alaskan Native

 Asian or Pacific Islander (includes Indian subcontinent)

 Hispanic/Latino (Spanish culture or origin, regardless of race)

 White (persons not of Hispanic origin, having origin in any of the

 Race not included above (Please specify):

original peoples of Europe, North Africa, or the Middle East)

_________________________________________________________

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 bachelor’s degree program in the 2013-2014

academic year. I hereby authorize the National Center for Learning Disabilities (NCLD) to use my personal statement, in whole or in part, as well as non-

financial information from my application for publicity and public relations purposes. I understand that information contained in my application 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 school officials and others to request additional relevant information for use by the Anne Ford Scholarship Selection Committee and/or NCLD staff. Signature of Applicant: _______________________________________________________

Date: _________________________

Signature of Parent or Guardian: _______________________________________________

Date: _________________________

(required if applicant is under 18)

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Personal Achievements & Activities Form

Name: __________________________________________________________________ Last

First

Middle

PART 1: ACADEMIC INFORMATION Grades:

You MUST submit a copy of your transcript.

Class Rank (if available): ________ out of ________

Standardized Testing: SAT:

You must submit either SAT or ACT scores.

Exam Date: _____ / _____ / _____

Best Score: Math ____ Critical Reading ____ Writing ____

Are you planning to take either test again?

Date of Birth: _____ / _____ / _____

 Yes

Month

Date

Year

Grade Point Average (GPA): ________ on scale of ________

ACT: Exam Date: _____ / _____ / _____ Best Score: Composite _____

 No

If you have taken any other standardized tests (AP, IB, SAT Subject, etc.) and would like to share your scores, please do so below:

_____________________________________________________________________________________________________________________

PART 2: EXTRACURRICULAR ACTIVITIES

List extracurricular activities (school clubs, sports, etc.) you have been involved in. If you need more room, you may attach another piece of paper. Activity

Grades Involved (all that apply)

 9

Hours per Week

Summer or School Year ( all that apply)

 10

 11

 12

 Summer

 9

 10

 11

 12

 Summer

 9

 11

 Summer

 10

 12

 School Year  School Year  School Year

Position Held, Awards/Honors, Other Achievements

PART 3: COMMUNITY AND WORK EXPERIENCE

List any community, volunteer, or work experience you have. If you need more room, you may attach another piece of paper. Activity

Grades Involved

Hours per Week

(all that apply)

 9

Summer or School Year ( all that apply)

 10

 11

 12

 Summer

 9

 10

 11

 12

 Summer

 9

 11

 Summer

 10

Position Held, Awards/Honors, Other Achievements

 School Year  School Year

 12

 School Year

PART 4: OTHER ACTIVITIES

List any other activities you have been involved in. If you need more room, you may attach another piece of paper. Activity

Grades Involved

Hours per Week

(all that apply)

 9

Summer or School Year ( all that apply)

 10

 11

 12

 Summer

 9

 10

 11

 12

 Summer

 9

 11

 Summer

 10

 12

Position Held, Awards/Honors, Other Achievements

 School Year  School Year  School Year

PART 5: SPECIAL INTERESTS, HONORS, AND AWARDS

Do you have any additional special interests or hobbies? If so, explain: ____________________________________________________________________

_____________________________________________________________________________________________________________________________ Since the 9th grade, have you received any special awards or honors? If so, list them: ___________________________________________________________ ______________________________________________________________________________________________________________________________ Feel free to submit any additional information or a resume as part of this application.

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Personal Statement

Please pay special attention to this part of the application. Together with information provided in letters of recommendation the personal statement is the best way for of the review committee to get to know you and understand your journey as a student with LD. This personal statement should describe your frustrations and triumphs in dealing with your specific learning disability. Feel free to express yourself in creative ways! Be sure that you share how you embody the characteristics of an ideal candidate as described in the introduction to the application. Your statement should make specific mention of how you believe a college education will enhance your life and how the Anne Ford Scholarship will help you achieve this goal.

Here are some key questions to think about as you write: •

Tell us about your learning disability. How it has affected you in school, at home, and in the community?

•

What are some examples of times you were able to overcome specific barriers to learning?

•

Who are the people in school, at home, or in the community who have helped you most?

•

What accommodations or assistive technologies have helped you succeed?

•

What do you want to study in college and why?

•

How would the Anne Ford Scholarship help you accomplish your goals?

Submit your personal statement as a written, typed essay of 750-1000 words.

The Anne Ford Scholarship Recommendation Form

All applications must be postmarked by December 31, 2012. Please return this form and any additional documentation to the student so it can be included in the completed application packet. Name of Applicant: ________________________________

Applicant Date of Birth: _____ / _____ / _____

The Anne Ford Scholarship is a $10,000 award given to a high school senior with a documented learning disability who will be enrolled in a full time bachelor’s degree program in the fall of 2013. The ideal Anne Ford Scholar is a student who: • • • • • • •

Has faced the challenges of having a learning disability (LD) with perseverance Is committed to completing a college degree and setting career goals Embraces new opportunities

Has a well-rounded perspective shaped by experiences at school and in the community

Understands how LD affects his or her life and recognizes the importance of self-advocacy Believes in contributing to society in ways that increase the potential of all people with LD

Would welcome opportunities to serve as a role model and spokesperson for others with LD

INSTRUCTIONS Step 1: Please provide the following information about yourself. Name:

Title:

School/Organization: Mailing Address: Telephone: (

)

-

ext.

How do you know the applicant? How long have you known the applicant?

Email:

Step 2: Please complete the rating scale below. Below

Average

Average

Above

Average

Well Above Average

Outstanding

I Don’t Know

Academic Achievement College Readiness Perseverance Motivation Self-advocacy Understanding of LD Leadership and Initiative Involvement in school/community activities

Role model/spokesperson for people with LD

Use of accommodations & s

Step 3: Please answer the following questions on a separate piece of paper. 1. Is this student an effective self-advocate? Explain.

2. How has this student reacted to setbacks or persevered in difficult situations? Please give examples if possible. 3. How well does this student understand his/her LD? Explain.

4. What are the three characteristics you most appreciate about this student? Feel free to provide additional about this student in your response.

Please return this form and completed additional pages to the student.

The Anne Ford Scholarship Recommendation Form

All applications must be postmarked by December 31, 2012. Please return this form and any additional documentation to the student so it can be included in the completed application packet. Name of Applicant: ________________________________

Applicant Date of Birth: _____ / _____ / _____

The Anne Ford Scholarship is a $10,000 award given to a high school senior with a documented learning disability who will be enrolled in a full time bachelor’s degree program in the fall of 2013. The ideal Anne Ford Scholar is a student who: • • • • • • •

Has faced the challenges of having a learning disability (LD) with perseverance Is committed to completing a college degree and setting career goals Embraces new opportunities

Has a well-rounded perspective shaped by experiences at school and in the community

Understands how LD affects his or her life and recognizes the importance of self-advocacy Believes in contributing to society in ways that increase the potential of all people with LD

Would welcome opportunities to serve as a role model and spokesperson for others with LD

INSTRUCTIONS Step 1: Please provide the following information about yourself. Name:

Title:

School/Organization: Mailing Address: Telephone: (

)

-

ext.

How do you know the applicant? How long have you known the applicant?

Email:

Step 2: Please complete the rating scale below. Below

Average

Average

Above

Average

Well Above Average

Outstanding

I Don’t Know

Academic Achievement College Readiness Perseverance Motivation Self-advocacy Understanding of LD Leadership and Initiative Involvement in school/community activities

Role model/spokesperson for people with LD

Use of accommodations & s

Step 3: Please answer the following questions on a separate piece of paper. 1. Is this student an effective self-advocate? Explain.

2. How has this student reacted to setbacks or persevered in difficult situations? Please give examples if possible. 3. How well does this student understand his/her LD? Explain.

4. What are the three characteristics you most appreciate about this student? Feel free to provide additional about this student in your response.

Please return this completed form and additional pages to the student.

The Anne Ford Scholarship Recommendation Form

All applications must be postmarked by December 31, 2012. Please return this form and any additional documentation to the student so it can be included in the completed application packet. Name of Applicant: ________________________________

Applicant Date of Birth: _____ / _____ / _____

The Anne Ford Scholarship is a $10,000 award given to a high school senior with a documented learning disability who will be enrolled in a full time bachelor’s degree program in the fall of 2013. The ideal Anne Ford Scholar is a student who: • • • • • • •

Has faced the challenges of having a learning disability (LD) with perseverance Is committed to completing a college degree and setting career goals Embraces new opportunities

Has a well-rounded perspective shaped by experiences at school and in the community

Understands how LD affects his or her life and recognizes the importance of self-advocacy Believes in contributing to society in ways that increase the potential of all people with LD

Would welcome opportunities to serve as a role model and spokesperson for others with LD

INSTRUCTIONS Step 1: Please provide the following information about yourself. Name:

Title:

School/Organization: Mailing Address: Telephone: (

)

-

ext.

How do you know the applicant? How long have you known the applicant?

Email:

Step 2: Please complete the rating scale below. Below

Average

Average

Above

Average

Well Above Average

Outstanding

I Don’t Know

Academic Achievement College Readiness Perseverance Motivation Self-advocacy Understanding of LD Leadership and Initiative Involvement in school/community activities

Role model/spokesperson for people with LD

Use of accommodations & s

Step 3: Please answer the following questions on a separate piece of paper. 1. Is this student an effective self-advocate? Explain.

2. How has this student reacted to setbacks or persevered in difficult situations? Please give examples if possible. 3. How well does this student understand his/her LD? Explain.

4. What are the three characteristics you most appreciate about this student? Feel free to provide additional about this student in your response.

Please return this completed form and additional pages to the student.

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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, 2012. Name of Applicant: ____________________________________

Applicant’s 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

Option 2:

Individual income reported by: •

•

tax return: $ _______________________ •

(IRS form 1040, Line 7)

•

Total number of exemptions claimed: ________

•

Father $_________ Mother $________

Student $________ Other $_________

List all of the household, ages, and relationship to the applicant: Name

Age

Relationship

Is this a single parent family?  Yes

Name

 No

Age Relationship

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 Annual Tuition Costs

Yes

Pending

Yes

Pending

Yes

Pending

Yes

Pending

Yes

Pending

Those candidates chosen for final review by the Selection Committee will be asked to submit copies of the most recent

Federal income tax returns and/or W-2 forms. Please attach any additional information you would like to share regarding

your financial situation.