American Council of the Blind

American Council of the Blind
2010 Scholarship Application

I: Personal Data

Name: (First, Middle, Last)

Gender:

Date of Birth:

Email:

Mailing Address: C/O

City:

Street:

State:

Zip Code:

Telephone Number: (listing the number most often available at first.)

Class level for upcoming fall term: Check one

Entering Freshmen
Full time

Part time

Undergraduate
Full time

Part time

Graduate
Full time

Part time

Vocational/Technical

(Note: Full time is considered 12 or more credit hours per term (semester or quarter) for undergraduates, and 9 or more credit hours for graduate students.)

Are you working full time (32 or more hours) and attending school?
Yes

No

Cumulative Grade Point Average:

Major field of study

Minor field of study

II: Visual Status

Please note: Legal blindness is defined as an individual who has a visual acuity of 20/200 or less in the corrected eye and/or 20 degrees or less visual field in the corrected eye. Legal blindness must exist in BOTH eyes to be considered eligible.

When did you begin having problems with your vision?

At what age did you become legally blind?

What was the cause of your visual impairment?

Visual Acuity: Right Eye:

Left Eye:

Visual Field: Right Eye:

Left Eye:

(Please include correct information. Do not refer to submitted eye report)

Can you see well enough to: Tell whether the light is on or off?
Yes

No

See steps going up or down?
Yes

No

Please describe the types of mobility aids you use to travel: (Check all that apply.)

Cane

Dog guide

Sighted guide

Low vision aids (specify)

Other devices (specify)

Please describe the types of adaptive communication tools that you use. (Check all that apply)

Braille

Screen readers

Large print

Note takers

Electronic readers

Magnification devices

Other (specify)

III: Education background

A. (Question A is for Entering Freshmen only)

High school currently attending: Name:

City and State:

Cumulative GPA (based on 4.0 scale):

B. University/college or vocational/technical school currently attending: Name:

City and State:

Full time or Part time
Full time

Part time

Cumulative GPA (based on 4.0 scale):

Date degree is expected:

Major(s) and Degree seeking (BS, MA, etc):

C. University/college you plan to attend in the fall of 2010, if different from question III B. Note: Proof of acceptance must be included with application materials. If you will not be notified by the time you submit this application, please indicate the date you expect to receive notice from the school(s).

1st Choice: Name:

City and State:

Major and Degree:

Full time or Part time
Full time

Part time

Date degree expected:

2nd Choice: Name:

City and State:

Major and Degree:

Full time or Part time
Full time

Part time

Date degree expected:

D. Please list any other schools you have attended during the last four years if different from above. Name:

City and State:

Dates (mo/yr) attended: From:

Dates (mo/yr) attended: To:

Cumulative grade point average (based on 4.0 scale):

Major and Degree or certificate received (if applicable):

IV: Test Record Information

ACT Date tested:

Composite Score:

SAT Date tested:

Composite Score:

SAT II Subject:

Date tested:

Composite Score:

Other (GRE, GMAT, LSAT, etc.) specify

Date tested:

Composite Score:

V: Work Experience

Please list any full-time or part-time work experiences that you have had in the last ten years. Indicate whether this was summer employment or during the school year.

VI: Extracurricular Activities:

A. Please list your extracurricular activities (school, religious, community, sports, organizations of the blind, recreation, etc.). Include the extent to which you have played a leadership role. A co-curricular transcript may be substituted.

VII: American Council of the Blind involvement:

A. Are you a member of the American Council of the Blind?

B. Have you received an American Council of the Blind Scholarship in the past? If so list what year(s). Your application will be shared with your state affiliate.

C. May we refer this application to another source of possible scholarship aid?

D. How did you hear about the American Council of the Blind scholarship program?

VIII: Autobiographical sketch:

A. Autobiographical sketch: No more than 500 words containing information about you. Tell us about your personal goals, strengths, weaknesses, hobbies, honors, achievements, etc. Be sure to list the field or courses of study you are pursuing and explain why you have chosen it.

Please review the entire scholarship application before submitting. Please refer to the instructions at the beginning of the application to ensure that your application is complete.

Return to ACB home page.

American Council of the Blind 2010 Scholarship Application

I: Personal Data

II: Visual Status

III: Education background

IV: Test Record Information

V: Work Experience

VI: Extracurricular Activities:

VII: American Council of the Blind involvement:

VIII: Autobiographical sketch:

American Council of the Blind
2010 Scholarship Application