ApplicAtion process checklistThis application should be completed by applicant’s parent(s) or guardian(s) in collaboration with applicant. Applicants may use additional paper if needed for responses.

p.A.c.e. application materials (available at www.nl.edu/pace)

o Application [to be completed by applicant’s parent(s) or guardian(s)]

o Behavioral Assessment [to be completed by applicant’s parent(s) or guardian(s)]

o Applicant Personal Statement*

o Three References* (to be completed by one educator and two non-relatives who have known the applicant for at least six months)

p.A.c.e. application supporting documents:

o Official Transcript high school diploma and/or certificate of completion (if applicable)

o 504 Plan (if applicable)

o IEP (if applicable)

o Achievement Testing (required)An educational evaluation completed within the past 18 months with specific subtest scores and age/grade equivalents and labeled from the Wechsler Individual Achievement Test (WIAT-II or III) or the Woodcock Johnson III (WJ-III). Please include the test’s Assessment Record Summary, Clinician Report, or Score Report, as well as the Student Profile sheet with standard scores and percentile ranks.

o Intellectual Assessment and Psychological Narrative (required)An intellectual assessment completed within the past 18 months using the Wechsler Adult Intelligence Scale-(WAIS) III or IV. Please include all subtests, raw scores,and Verbal, Performance, Full scale scores as recorded by the test administrator on the Intellectual Assessment Protocol sheet, as well as a full narrative written report.

o Credentials of Evaluators (required) The test administrator’s personal title and license or credentials on a separate with page, name, address and phone.

o Specific Testing (optional)Note the following for Language/Communication challenges: if the applicant has significant language challenges (expressive or receptive), you may include an additional cognitive evaluation utilizing the Wechsler Nonverbal Scale of Ability (WNV), 2006 Edition. A written report is preferred but not necessary. Please list and identify all subtests, raw scores, T-scores and total scores.

o Other Assessments (optional)Copies of any psychological or educational tests and reports completed within the last three years and related school/professional reports. Such as occupational therapy, speech/language therapy, Behavioral Therapy, Assistive technology assessment.

* Additional requirements may be necessary. Also, specific programs may have additional requirements prior to registration. The decision to deny admission cannot be appealed. P lease contact your NLU Enrollment Specialist for complete details.

p.A.c.e. at national louis UniversityAdmission reqUirements checklist

P.A.C.E. Office of Admissions | 5202 Old Orchard Road | Skokie, IL 60077 UNIV-1104-PACE-App-Checklists-17Sept2013

P.A.C.E. Office of Admissions | 5202 Old Orchard Road | Skokie, IL 60077

scholarship Application (optional)

o Scholarship Application should be completed no later than April 1, 2014.

o FREE Application for Federal Student Aid (FAFSA) should to be completed and submitted to National Louis University no later than April 1, 2014 for priority consideration. An electronic form can be obtained at www.fafsa.ed.gov. National Louis University school code is 001733; we are only listed with our Chicago, IL campus address. Please choose this option regardless of which campus you will be attending.

Send all application checklist materials, scholarship application and $40 non–refundable application fee (check or money order made payable to P.A.C.E.) to the following address:

p.A.c.e. at national louis University5202 old orchard road skokie, il 60077

Following receipt and review of all required admissions materials, a determination will be made to extend an offer of an on-campus interview, the final step of the admission process.

Notification letters will be mailed approximately one week after the admission decision is made.

ApplicAnt informAtion

Last Name First Name Middle Name

Street Address

City State Zip

Permanent Street Address

City State Zip

Home Phone Cell Phone

Email Address Date of Birth*

Social Security Number (SSN)* Gender

*The applicant’s SSN and date of birth are confidential and protected under federal law from being disclosed to unauthorized parties.

Is the applicant a U.S. Citizen? o Yes o No

If no, is the applicant a Permanent Resident of the U.S? o Yes o No

What language(s) does the applicant speak?

Ethnic Background (optional information). Please select from BOTH ethnic and racial identification sections to help the university meet its federal reporting obligations.

Applicant’s Ethnicity (optional information) o Hispanic or Latino o Not Hispanic or Latino

Please Select One or More Races o American Indian or Alaska Native o Asian o White

o Native Hawaiian or Other Pacific Islander o Black or African American

Has the applicant applied for Vocational Rehabilitation (VR) services? o Yes o No

Does the applicant receive Vocational Rehabilitation services? o Yes o No

If yes, please list the VR counselor’s name and contact information

Is the applicant receiving Social Security Insurance (SSI)? o Yes o No

Please explain

p.A.c.E. at national louis UniversityAdmission ApplicAtion

P.A.C.E. Office of Admissions | 5202 Old Orchard Road | Skokie, IL 60077 UNIV-1105-PACE-AdmissionApplication-17Sept2013

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How did you learn about the P.A.C.E. program at National Louis University?

o School Teacher/Counselor/Principal o Flyer o Friend/Alumni

o Conference/Fair o Agency/Service Provider o Internet Search o Other _________

fAmily/GUArdiAn informAtion

Is the applicant his/her own guardian? o Yes o No

If no, are you the legal guardian of your applicant? o Yes o No

If no, have you or do you plan to apply to be his/her legal guardian? o Yes o No

mother/Guardian o Primary Contact o Secondary Contact Method of Communication o Phone o Email

Last Name First Name Middle Name

Street Address

City State Zip

Employer/Occupation Work Phone

Email Address Cell Phone

Highest Level of Education Completed: o High School o Bachelor’s o Master’s o Doctorate

father/Guardian o Primary Contact o Secondary Contact Method of Communication o Phone o Email

Last Name First Name Middle Name

Street Address

City State Zip

Employer/Occupation Work Phone

Email Address Cell Phone

Highest Level of Education Completed: o High School o Bachelor’s o Master’s o Doctorate

siblings (indicate the age, gender or any other relevant information of applicant’s siblings)

name Age Gender other relevant information

Ap

plicant n

ame _______________________________________________________________

Why are you interested in the P.A.C.E program for this applicant?

Describe the applicant’s attitude toward moving away from home to attend college.

Describe the family’s concerns about the applicant moving away to attend college.

Describe any concerns you may have about the applicant’s ability to successfully participate in the P.A.C.E program.

Describe how you are preparing the applicant for the transition to college.

Indicate where the applicant has stayed overnight away from his/her primary caregiver(s) and for how long. (please mark all that apply)

o Camp _____________ o School ___________ o Vacation _________ o Other ____________ o NA

What level of supervision did the applicant have? (please mark all that apply) o 24 hour o One-to-one o Small group

Describe adjustment challenges and effective strategies.

Has the applicant used public transportation on his/her own to get to school or work? o Yes o No

Does the applicant use a cell phone independently? o Yes o No

Do you understand that the applicant will be required to have a cell phone in the P.A.C.E. program? o Yes o No

Does the applicant have a driver’s license? o Yes o No

EdUcAtion History of ApplicAnt (include primary, secondary and any post-secondary experience)

name of school location public, privet, transition or other

years Attended

completed (Y or N)

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Did the applicant participate in general education setting during secondary school? o Yes o No

If yes, did the applicant have an aide in the regular classroom? o Yes o No

Describe the type of support the aide provided.

What type of special education support did the applicant receive outside of regular education classrooms?

What type of instruction did the applicant receive in resource classrooms and for how long?

o One-to-one instruction _________________________________________________

o Small group instruction _________________________________________________

Please indicate the applicant’s level of independence of completing homework assignments.

o Completely independent o Reviewing with adult o Direct assistance

Does/did the applicant have an IEP or 504 Plan? o Yes o No (submit a copy with the application materials)

When did or will the applicant complete his/her high school education? Month ________________ Year _____________

Was a high school diploma or a certificate of attendance awarded? o Yes o No

If the applicant has not graduated, is a high school diploma or a certificate expected? o Yes o No

What type? o Standard o Modified Standard o Special o Other ____________________________

sUpportivE sErvicEs** (provide information on the support services the applicant received in school)

type of service duration of service description of Applicants AccommodationsOccupational Therapy

Physical Therapy

Speech and Language

Assistive Technology

Social Work

Other (please specify)

Ap

plicant n

ame _______________________________________________________________

5

privAtE tHErApEUtic sErvicEs** (provide information on the services the applicant received outside of school)

type of service duration of service

does the service need to continue (Y or N)

reason the service needs to continue

Occupational Therapy

Physical Therapy

Speech and Language

Assistive Technology

Mental Health

Other (please specify)

** P.A.C.E. program fees and tuition do not include the cost of these services if continued.

Please indicate, in your opinion, the most effective learning strategies for the applicant

o Auditory o Reading o Visual Presentations/Organizers

o Memorization o Repetition o Experiential Learning

Describe how the applicant compensates for learning or cognitive disabilities when managing a task.

Describe any technology or assistive technology the applicant has used to assist in living, learning or working.

ExtrAcUrricUlAr ActivitiEs

organization name description of Activity dates Hours per Week

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EmploymEnt/volUntEEr ActivitiEs

name of Employer

position and Job responsibilities

dates of Employment Hours per Week

reason for leaving

paid or volunteer (P or V)

Used a job coach? (Y or N)

What accommodations were provided at work? (e.g., visual cues, prompts, etc.)

To assist us with internship placement, describe the circumstances regarding any difficult work/volunteer experiences

mEdicAl/disABility History

Applicant’s Physician Name Office Phone

Street Address

City State Zip

Does the applicant have problems with incontinence? o No o Yes, please explain _____________________________

Does the applicant require mobility assistance? o No o Yes, please explain ___________________________________

If so, does the applicant use mobility aids? o No o Yes, please explain ________________________________________

Does the applicant require any canine assistance? o No o Yes, please explain __________________________________

Has the applicant ever had a seizure? o No o Yes, please explain and provide dates and medical treatment.

Ap

plicant n

ame _______________________________________________________________

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Provide information on all medical conditions or diagnosis, other than common childhood illnesses.

medical condition date of diagnosis

description of the medical condition

does this impact the daily living of the applicant? (Y or N)

Provide list all CURRENT prescription medications. (use additional paper if needed to complete list)

medication dose purpose side Effects

Provide list all PREVIOUS prescription medications. (use additional paper if needed to complete list)

medication purpose Why discontinued

Please indicate the applicant’s ability on each task below.

medication skills completely independent

minimal Assistance

moderate Assistance

complete Assistance

not Applicable

Organizes medications daily or weekly

Understands what medication to take at correct times daily

Understands what medication to take in response to symptoms

Does the applicant understand why he/she is taking each of his/her medications? o Yes o No

Please elaborate ___________________________________________________________________________________________

Applicant’s Hospitalization Historydates of Hospitalization reason for Hospitalization

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Please describe applicant’s history of aggressive physical or verbal behavior, if applicable ________________________

Please describe applicant’s history of legal violation, arrest or probation, if applicable ____________________________

rEfErEncEs

Three reference forms should be completed by non-relatives who have known the applicant for at least six months. One reference must be from an educator. Other references should be an educator, supervisor, employer, family friend, or a service provider. These forms should be sent directly to the P.A.C.E. program by the references. The reference forms must be received by the application date you wish for your application to be considered (See Application Checklist).

1. Name Title

2. Name Title

3. Name Title

My signature below indicates that all information contained in this application is factually correct and complete. I understand that the misrepresentation or omission of application information is sufficient grounds for canceling my admission or registration.

Applicant Signature Date

My signature below indicates that all information contained in this application is factually correct and complete. I understand that the misrepresentation or omission of application information is sufficient grounds for canceling applicant’s admission or registration.

Parent /Guardian Signature Date

National Louis University admits students to all programs and activities and administers all educational, employment, and other policies without discrimination because of race, color, age, religion, gender, sexual orientation, ancestry, disability, military status or marital status.

Ap

plicant n

ame _______________________________________________________________

This form should be completed by the parent/guardian or primary caregiver. Please honestly evaluate the applicant’s ability in each of the areas below. You may place a checkmark in the Don’t Know column if you do not have information necessary to evaluate the applicant for a specific skill. Please type or print legibly.

Applicant’s Name Form Completed by

Independent Living Skills Completely Independent

Minimal Assistance

Moderate Assistance

Complete Assistance

Don’t Know

Exercises good grooming behaviors — brushes hair and shaves daily

Showers independently on a daily basis

Exhibits good hygiene — brushes teeth, trims nails and washes hands

Uses an alarm to wake up; goes to sleep at a reasonable time

Budgets time and uses a schedule

Understands time needed to complete different tasks (e.g., cleaning room, personal care, homework)

Prepares a simple, healthy meal, packs a lunch

Utilizes kitchen appliances to prepare meals

Cleans kitchen area and dishes after eating

Does laundry — uses a washing machine, dryer and iron

Maintains a clean and organized living area — ie., makes bed daily, puts clothes away

Is able to stay home alone

Understands emergency procedures

Please include any additional comments on independent living skills

P.A.C.E. at National Louis UniversityBEHAVIORAL ASSESSMENT

P.A.C.E. Office of Admissions | 5202 Old Orchard Road | Skokie, IL 60077 UNIV-1106-PACE-Behavioral-Assessment-10Sept2013

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Interpersonal Skills Completely Independent

Minimal Assistance

Moderate Assistance

Complete Assistance

Don’t Know

Greets people appropriately

Communicates needs and opinions to others effectively

Engages in informal conversations

Establishes and maintains relationships with friends

Enjoys spending time alone with friends

Engages in social activities independently

Plans social events

Responds appropriately to authority figures

Has ability to problem solve

Recognizes and manages his/her emotions

Recognizes and responds appropriately to the emotions of others

Uses a cell phone

Please include any additional comments on interpersonal skills

Ap

plicant N

ame _______________________________________________________________

3

Career Skills (if applicable) Completely Independent

Minimal Assistance

Moderate Assistance

Complete Assistance

Don’t Know

Attends work regularly

Arrives on time and takes appropriate breaks

Dresses appropriately for job and weather

Meets hygiene expectations in the work environment

Cooperates with supervisor

Able to work as a team member and get along with co-workers

Follows written directions

Follows verbal directions

Asks questions/for clarification when needed

Completes assigned work tasks

Follows appropriate safety procedures

Recognizes areas that need improvement

Works to improve performance

Responds to feedback appropriately

Please include any additional comments on career skills

Computer Skills Completely Independent

Minimal Assistance

Moderate Assistance

Complete Assistance

Don’t Know

Turns computer and accessories on and off

Uses a mouse to move the cursor, drag an object or switch programs

Composes and type a paragraph in a word processing program

Starts up and uses browser to access information on the web

Logs into a computer station and email account

Uses common e-mail functions such as creating, sending and replying

Uses Facebook or other electronic social networks

Please include any additional comments on computer skills

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Please rate the applicant on each of the characteristics in the areas of school, job and home. Please consider the specific setting for each of the qualities or skills. For any areas you do not feel qualified to provide a response, write N/A in the specific blank.

QUALITIES

General (scale 1=low 5=high) SCHOOL JOB HOME

Initiative _________ _________ _________

Responsibility _________ _________ _________

Maturity _________ _________ _________

Reliability _________ _________ _________

Ability to use good judgment _________ _________ _________

Determination _________ _________ _________

Attitude _________ _________ _________

Comments — describe qualities that need further development

Emotional Adaptability (scale 1=low 5=high) SCHOOL JOB HOME

Ability to cope with stress _________ _________ _________

Adjusts well to newer situations or environments _________ _________ _________

Ability to keep problems in perspective _________ _________ _________

Comment on types of situations that are stressful for applicant and coping mechanisms used

Interpersonal (scale 1=low 5=high) SCHOOL JOB HOME

Ability to relate to teachers _________ _________ _________

Ability to relate to young children _________ _________ _________

Ability to relate and interact with same-age peers _________ _________ _________

Ability to relate to elderly people _________ _________ _________

Ability to relate to people with disabilities _________ _________ _________

Maintains positive relationships with adults _________ _________ _________

Comment on style of interaction and specific strengths and weaknesses

Ap

plicant N

ame _______________________________________________________________

Instructions: This section should be completed by the applicant. Applicant may have someone assist with recording the exact responses. Note: Parents/Guardians — Please do not fill this section out for the applicant.

Applicant Name

Why are you interested in the P.A.C.E. program at National Louis University?

What do you want the P.A.C.E. program to teach you?

What concerns or fears do you have about participating in the P.A.C.E. program?

What would you like to do after you complete the P.A.C.E. program? (for example: community college, four year university, work, travel, etc.)

What were your least favorite subjects? Why did you not like them?

What do you do well?

What do you want to learn to do better?

Have you lived away from your parent(s)/guardian(s)? (for example: camp, school, vacation) o Yes o No

P.A.C.E. at National Louis UniversityAPPLiCANt PErsoNAL stAtEmENt

P.A.C.E. Office of Admissions | 5202 Old Orchard Road | Skokie, IL 60077 UNIV-1109-PACE-PersonStatement-10Sept2013

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If yes, what did you like about being away from home?

If yes, what was hard about living away from home?

Have you ever shared a bedroom with another person? o Yes o No

If yes, describe what you enjoyed and did not enjoy about sharing a room?

What time do you go to bed on school/work nights?

What chores do you enjoy doing at home?

What chores are difficult for you?

If you have any work or volunteer experience, what did you like and dislike about it?

Please rank the top three career areas you are interested in exploring within the P.A.C.E. program by placing a 1, 2 and 3 in the boxes:

o Adult Care o Animal Care o Child Care o Clerical Support

o Health Care o Hospitality o Sales/Retail o Technology

o Other ______________

Why are you interested in exploring these careers?

What type of activities do you like to do with family and friends?

Ap

plicant N

ame _______________________________________________________________

How often do you spend time with your friends outside of school? (please check one)

o Once a month o Several times a month o Once a week o Several times a week

What types of music do you enjoy?

What are some of your favorite movies, television shows and web sites?

What are you other hobbies?

Please include any additional information you would like to share with us

Applicant Signature Date

If application was written on applicant’s behalf, please identify your name and relationship

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e _

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Please complete the top section of this reference form before giving it to each of your references. Of the three references, one must be an educator, and the balance can be completed by employer, supervisor, family friend or service provider. Reference must have know applicant for six months or more. Reference form should be sent directly to the P.A.C.E. program by the person completing the form.

Applicant Last Name Applicant First Name Applicant Middle Name

Applicant Street Address

City State Zip

Waiver Statement: I understand this reference form and behavioral assessment is to be submitted and maintained in confidence by National Louis University admission consideration to the P.A.C.E. program. I hereby waive all rights I may have to access these documents under the Family Education Rights and Privacy Act of 1974, and any/all other laws, regulations or policies. I understand the rights I am waiving include, but are not limited to, the right to review these documents; the right to have a copy of these forms; and/or the right to request an amendment to any of the documents.

o I agree to waive my access to these documents.

o I do not agree to waive my access to these documents.

Applicant Signature Applicant Name (printed) Date

Parent /Guardian Signature Parent /Guardian Name (printed) Date

Please mail completed form to:

P.A.C.E. Office of Admissions

5202 Old Orchard Road

Skokie, IL 60077

P.A.C.E. at National Louis UniversityCONfIdENtIAL REfERENCE fORm

P.A.C.E. Office of Admissions | 5202 Old Orchard Road | Skokie, IL 60077 UNIV-1118-PACE-ConfidRef-16Sept2013

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Note to Reference: The applicant named on page 1 is applying for admission to the P.A.C.E. program at National Louis University. The P.A.C.E. program is a 2 year comprehensive residential certificate program for motivated young adults with learning and/or intellectual disabilities. P.A.C.E. educates and empowers students to become independent, productive adults. P.A.C.E. students are expected to be emotionally stable so to not interfere with their ability to participate or affect any other students participation in the program. The applicant and parent(s)/guardian(s) have been asked to waive their rights to access the recommendation form; however, if they did not waive their rights, then they may request a copy of this form at any time. Please honestly complete this reference form and behavioral assessment tot he best of your ability. For inquiries, contact us at 224.233.2670 or at PACE@nl.edu.

Reference Last Name Reference First Name Reference Middle Name

Reference Street Address

Organization Position

Work Phone Email Address

How long and in what capacity have you known the applicant?

Describe some of the applicant’s strengths that would allow him/her to succeed in them P.A.C.E. program. Include some examples of times he/she has demonstrated these qualities.

Describe some of the applicant’s areas in need of improvement. Please include information that may be useful to the P.A.C.E. staff and faculty to support the applicant in these areas.

Do you believe the parents/guardians will support the philosophy/goals of the P.A.C.E. program? If so, in what way?

Please describe any concerns you may have that would impact the applicant’s ability to be successful at P.A.C.E.

Please describe any known limitations that would prevent the applicant from being involved in physical activities

essential to vocational training or independent living goals.

Ap

plicant N

ame _______________________________________________________________

Please indicate the most effective learning strategies for the applicant

o Auditory o Reading o Visual Presentations/Organizers

o Memorization o Repetition o Experiential Learning

o Other ______________

Describe how the applicant compensates for his/her learning or intellectual disabilities when managing a task.

Please provide any additional supporting information that you may have regarding this applicant.

BEhAvIORAL ASSESSmENt

Please rate the applicant on each of the characteristics in the areas of school, job and home. Please consider the specific setting for each of the qualities or skills. For any areas you do not feel qualified to provide a response, write N/A in the specific blank.

QUALItIES

General (scale 1=low 5=high) SCHOOL JOB HOME

Initiative _________ _________ _________

Responsibility _________ _________ _________

Maturity _________ _________ _________

Reliability _________ _________ _________

Ability to use good judgment _________ _________ _________

Determination _________ _________ _________

Attitude _________ _________ _________

Comments — describe qualities that need further development

Ap

plic

ant

Nam

e _

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Emotional Adaptability (scale 1=low 5=high) SCHOOL JOB HOME

Ability to cope with stress _________ _________ _________

Adjusts well to newer situations or environments _________ _________ _________

Ability to keep problems in perspective _________ _________ _________

Comment on types of situations that are stressful for applicant and coping mechanisms used

Interpersonal (scale 1=low 5=high) SCHOOL JOB HOME

Ability to relate to teachers _________ _________ _________

Ability to relate to young children _________ _________ _________

Ability to relate and interact with same-age peers _________ _________ _________

Ability to relate to elderly people _________ _________ _________

Ability to relate to people with disabilities _________ _________ _________

Maintains positive relationships with adults _________ _________ _________

Comment on style of interaction and specific strengths and weaknesses

May we contact you for further information if necessary? o Yes o No

If yes, what is your preferred method of contact? o Phone o Email

Ap

plicant N

ame _______________________________________________________________

thE fOLLOWING SECtION IS fOR EdUCAtORS ONLY

(For all others, please go to the last section to complete the form by signing the document.) As you comment about the applicant below, please consider how the applicant compares to all students you have had contact with multiple learning and cognitive disabilities.

Please rank the applicant using the following guideline.

_________ Top 5% ________ Top 10% __________Top 25% ________ Top 50%

Please provide some rationale and examples for this rank based on the applicant’s

Academic strengths

How does the applicant show motivation/interest in learning

Give examples of growth in skills

Please rate the applicant in the following areas by placing an X in the appropriate box.

Excellent very Good Average Below Average

don’t Know

Leadership

Initiative

Adaptability

Perseverance

Academic Motivation

Academic Growth

Commitment to Community

Trustworthy

Integrity

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Please cite specific examples of how the applicant has demonstrated the qualities listed above.

Describe an academic challenge this applicant encountered and how he/she responded.

Describe any contributions the applicant has made to the school or community.

Thank you for dedicating the time to complete this recommendation as we value the insights you are able to provide us regarding the applicant.

Reference Signature Date

National Louis University admits students to all programs and activities and administers all educational, employment, and other policies without discrimination because of race, color, age, religion, gender, sexual orientation, ancestry, disability, military status or marital status.

Ap

plicant N

ame _______________________________________________________________

P.A.C.E. scholarships have been established through appeals to generous foundations and private donors to recognize students persevering to complete their studies in the NLU P.A.C.E. certificate program. Selection will be based primarily on the student’s financial need, and the amounts granted vary from year-to-year. On average, awards range between $1,000 and $5,000. To be considered for a P.A.C.E. scholarship, please fill complete the following information and email it to stscholarships@nl.edu. Additionally, a completed 2014–2015 FAFSA application is required. The application can be completed at www.fafsa.gov. NLU’s school code is 001733. Completed applications must be returned by April 1st, 2014 to be considered for the 2014–2015 school year.

Applicant Name

Applicant’s NLU ID number or Social Security Number

Parent/Guardian name(s)

Street Address

City State Zip

Home Phone Cell Phone

Email Address (required)

On a separate page, please attach your answers to the following questions:

1. As the applicant’s parent/guardian, please explain how the P.A.C.E. program has benefitted or would benefit your son/daughter?

2. Please provide any additional information that you feel would help the scholarship committee determine your applicant’s eligibility for the P.A.C.E. scholarship. You may include information regarding applicant’s career/life goals, and/or your personal/family situation. Since priority is given to applicants based on need, if you have extenuating circumstances that reflect your need that would not be evident in the FAFSA application, please discuss those circumstances in detail.

DeclArAtion AnD consent:

I confirm that the information provided on this application and accompanying documentation is complete and accurate. I authorize the University to release a copy of this application to the award donor, including any attached information. I understand that the P.A.C.E. office will send me written notification of the results of this application. Decisions will be made by April 30, 2014.

Signature Date

P.A.c.e. at national louis University2014–2015 scholArshiP APPlicAtion

P.A.C.E. Office of Admissions | 5202 Old Orchard Road | Skokie, IL 60077 UNIV-1110-PACE-Scholarship_Application_17Sept2013