LGMD Awareness Merit Based Scholarship Application

Transcription

1 9725 Third Avenue NE, Suite 204 Seattle, Washington USA Phone: Fax: LGMD Awareness Merit Based Scholarship Application Basic Information First Name: Last Name: Middle Name: Previous Name: Date of Birth: (MM/DD/YYYY) Gender: Female Male Permanent Address Street Address: City: Zip Code: State/Province: Country: US Citizen: Yes No Phone number: address: High School Information Currently attending?: Yes No School Name: Street Address: City: Zip Code: High school graduation year: State/Province: Country: Phone number: Post-Secondary School Information Currently attending?: Yes No School Name: (leave blank if not enrolled) Street Address: City: Zip Code: Anticipated graduation year: State/Province: Country: Phone number: How did you hear about this scholarship? completed application to or mail to rd Ave NE, Suite 204, Seattle, WA 98115

2 Academic Record Please provide your most recent high school GPA and post-secondary school GPA, if applicable, including the GPA scale. Unofficial school transcripts are required. SAT and ACT scores are optional, but the most complete applications will be given the greatest consideration. Please unofficial copies of school transcripts, SAT and ACT scores to GPA Scale: High School GPA: (4.0 scale, etc) GPA Scale: Post-secondary School GPA: (4.0 scale, etc) SAT score (optional): ACT score (optional): Extracurricular Activities Please list your extracurricular activities, the beginning and end dates of your involvement and describe your role highlighting any leadership experience or significant accomplishments. If all of your activities do not fit on this sheet, please submit an additional page.

3 Extracurricular Activities (continued)

4 Spreading LGMD Disease Awareness Limb Girdle Muscular Dystrophies (LGMDs) are rare diseases but they have a huge impact on the lives of everyone they touch. Ask at least 25 people whether they have heard of LGMDs and teach them about the diseases using the information provided at If they have already heard of LGMDs, ask them how they learned about them and what they know about the diseases before teaching them additional information. Individuals with muscular dystrophy might not know they have a problem until they notice that they have difficulty standing on their toes or standing from a sitting position on the ground without using their hands. If possible, ask the people you teach about LGMDs whether they can do these simple tasks to illustrate some of the abilities lost to people who develop LGMDs. After you have discussed the diseases, have them sign the form on page 5. Please be assured that names and contact information will not be shared with any third parties and addresses/phone numbers will not be added to any mailing lists. Contact information will only be used to confirm that scholarship finalists spoke with the individuals on their lists. If you are not a scholarship finalist, no one on your list will be contacted. Teaching more than 25 people about LGMDs will increase your overall application score. Maximum points will be awarded for interviewing 100 people. How many people did you talk to about LGMDs? How many people had heard of LGMDs before? If anyone had heard of it before, how did they hear about the diseases? Was anyone you talked with unable to stand on their toes or stand from a sitting position on the ground without using their hands? Yes No If anyone could not, did you tell them they may be eligible for free genetic sequencing at Yes No

5 We are always looking for creative new ways to spread disease awareness. What do you think we should do to make more people aware of LGMDs and how can we implement your ideas? (250 words or less) Describe how you taught people about LGMDs and what you did to help them remember something about the diseases in the future. (250 words or less)

6 List of individuals interviewed (25 interviews are required, maximum points are awarded for interviewing 100 people) Names and contact information will not be shared with any third parties and addresses/phone numbers will not be added to any lists. Contact information will only be used to confirm that scholarship finalists spoke with the individuals on their lists. If you are not a scholarship finalist, no one on your list will be contacted First and last name How you spread disease awareness: address/phone number

7

8

9

10

11

12

13

14

15 completed application to or mail to rd Ave NE, Suite 204, Seattle, WA 98115