Scholarship Form

Name___________________________________ Birthdate ____________________________________

Permanent Address_____________________________________________________________________

City ____________________ State ____________________ Zip ______________________________

Home Phone ____________________________ School Phone _______________________________

Racial/Ethnic Group (optional) _________________________________ Gender __________________

School last attended __________________________________________ Cum GPA _______________

School Currently enrolled _____________________________________ Cum GPA _______________

Address ______________________________________________________________________________

School Phone ____________________________ Fax _______________________________________

Name of recommender _______________________________________________

Association ___________________________________________________________________________

Name of Physician _____________________________________________________________________

Phone _______________________________________________________________________________

Honors/Awards or Extracurricular: _________________________________________________________

______________________________________________________________________________________

Activities: _____________________________________________________________________________

______________________________________________________________________________________

Volunteer Activities and/or Employment: ____________________________________________________

______________________________________________________________________________________

Hobbies or unique qualities: ______________________________________________________________

______________________________________________________________________________________

Essay Topic: Please attach an essay entitled "How Lupus Has Affected My Life." It must be 500 words or less, typewritten, and double- spaced.

AGREEMENTS: If I am selected as a recipient of The L.I.F.E. Scholarship, I give permission to the Foundation to publicly announce my name. I understand that I will be identified as a college student with Lupus.

Applicants Signature ___________________________________ Date ____________________________

(Do not sign the above if you do not wish to be identified).

I certify that all of the information I have provided in my application is complete and accurate to the best of my knowledge.

Applicants Signature ___________________________________ Date ____________________________