anne ford scholarship 20122013

7/27/2019 Anne Ford Scholarship 20122013

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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


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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 bachelors degree

program.

The ideal Anne Ford Scholar is a student who:

Articulates his/her LD and clearly demonstratesthe importance of self-advocacy

Is committed to completing a four-year collegedegree and has begun to set realistic career goals

Plans to contribute to society in ways that increaseopportunities for individuals with LD

Excels as a role model and spokesperson for otherswho struggle with LD

Demonstrates financial needEligibility & Selection Criteria

To be eligible for the 2012-2013 Anne Ford Scholarship,

an applicant must:

Have an overall Grade Point Average (GPA) of 3.0or 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. citizenPlease Note: If you will be attending a two-year communitycollege, 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 atwww.LD.orgfor more information on the

Allegra Ford Thomas Scholarship.You may not apply to

both scholarships.

Mentoring & OutreachOpportunities

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 theiracademic 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 passing grades

(transcripts).

Selection ProcessThe Anne Ford Scholarship Committee, comprised of

members of NCLDs 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 thescholarship packet. All required materials must be received

in one packet.

Questions?

First, please check out theFrequently Asked Questionson

our website. If your question is not answered there, you

may contact us.

Email:[email protected]

Phone: (888) 575-7373
http://www.ld.org/http://www.ld.org/http://www.ld.org/http://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqhttp://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqhttp://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqmailto:[email protected]:[email protected]:[email protected]:[email protected]://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqhttp://www.ld.org/


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2 Application Requirements Checklist

The Anne Ford Scholarship is for graduating high school seniors who will be attending a four-year, bachelors 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 atwww.LD.orgto 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 1401New York, NY 10016

Applications MUST be postmarked byDecember 31, 2012.

Please note that any materials submitted as part of the application process will not be returned.
http://www.ld.org/http://www.ld.org/http://www.ld.org/http://www.ld.org/


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3 Basic Information FormPlease write legibly or type in your answers.

APPLICANT INFORMATION PARENT/GUARDIAN INFORMATION

Applicant Name:

Last First Middle

Parent/Guardian Name(s):

Date of Birth: / /

Month Day Year

Mailing Address (if different from applicant):

Mailing Address: City: State: Zip Code:

City: State: Zip Code: Parent/Guardian Home Phone (if different from applicant):

Home Phone: Cell Phone: Parent/Guardian Cell Phone:

Applicant Email Address (Use block letters):

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

Parent/Guardian Email Address (Use block letters):

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

Are you a United States Citizen?* Yes No

*Applicants must be current U.S. citizens. If you have questions about your eligibility

for this award, send your inquiry [email protected].

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

Parent Legal Guardian Other Relative (specify): ___________

Other (specify): __________________
mailto:[email protected]:[email protected]:[email protected]:[email protected]


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SCHOOL HISTORY

High School(s):

Name of School City/State Years Attended

Middle School (s):


Primary/Elementary School(s):


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) Listening Comprehension (and processing) Executive Functioning/Organization Skills

Reading Fluency Skills (Dyslexia) Written Expression (Dysgraphia) Non-verbal LD

Spelling Math Calculation (Dyscalculia) Other (please explain):

_____________________________________ Reading Comprehension (Dyslexia) Math Problem Solving (Dyscalculia)

Date of Initial Diagnosis/Classification: ________________________________ Date of Most Recent Testing: __________________________________


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(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, Aspergers 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

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

Race not included above (Please specify):_________________________________________________________

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 disabil

will be earning my high school diploma or its equivalent, and will be enrolling for the first time in a full-time bachelors 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 fo

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 contact 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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4 Personal Achievements & Activities FormName: __________________________________________________________________ Date of Birth: _____ / _____ / _____

Last First Middle Month Date Year

PART 1: ACADEMIC INFORMATION

Grades: You MUST submit a copy of your transcript. Grade Point Average (GPA): ________ on scale of ________

Class Rank (if available): ________ out of ________

Standardized Testing: You must submit either SAT or ACT scores.

SAT: Exam Date: _____ / _____ / _____

Best Score: Math ____ Critical Reading ____ Writing ____

ACT: Exam Date: _____ / _____ / _____

Best Score: Composite _____

Are you planning to take either test again? Yes 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)

Hours per Week Summer or School Year( all that apply)

Position Held, Awards/Honors, Other Achievements

9 11

10 12

Summer

School Year

9 11

10 12

Summer

School Year

9 11

10 12

Summer

School Year


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PART 3: COMMUNITY AND WORK EXPERIENCE

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

Activity Grades Involved

(all that apply)

Hours per Week Summer or School Year

( all that apply)


9 11

10 12

Summer

School Year

9 11

10 12

Summer

School Year

9 11

10 12

Summer

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

(all that apply)

Hours per Week Summer or School Year

( all that apply)


9 11

10 12

Summer

School Year

9 11

10 12

Summer

School Year

9 11

10 12

Summer

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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5 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 members 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 thecommunity?

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.


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Recommendation Form

All applications must be postmarked byDecember 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 bachelors degree program in the fall of 2013.


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 ofallpeople 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. Email:

How do you know the applicant?

How long have you known the applicant?


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Step 2: Please complete the rating scale below.

Below

Average

Average Above

Average

Well Above

Average

Outstanding I Dont

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 & supports

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 feedback about this student in your response.

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


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Recommendation Form








INSTRUCTIONS


Name: Title:


Mailing Address:





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Below

Average

Average Above

Average

Well Above

Average

Outstanding I Dont

Know


College Readiness

Perseverance

Motivation

Self-advocacy

Understanding of LD



activities


with LD





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


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Recommendation Form








INSTRUCTIONS


Name: Title:


Mailing Address:





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Below

Average

Average Above

Average

Well Above

Average

Outstanding I Dont

Know


College Readiness

Perseverance

Motivation

Self-advocacy

Understanding of LD



activities


with LD





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


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6 Financial StatementTo be filled out by the applicants parent(s) or legal guardian.

Completed application packet must be postmarked no later than December 31, 2012.

Name of Applicant: ____________________________________ Applicants Date of Birth: _____ / _____ / _____

STATEMENT OF INCOME (Please select an option below.)

Option 1:

Total income as reported on households (applicantand parent/guardian) most recent federal income

tax return: $ _______________________

(IRS form 1040, Line 7)

Total number of exemptions claimed: ________

Option 2:

Individual income reported by:

Father $_________ Mother $________ Student $________ Other $_________

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

Name Age Relationship Name Age Relationship

Is this a single parent family? Yes No 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.

anne ford scholarship 20122013

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