Stroke Retreat 2014
Scholarship Application
Name:
_____________________________________
Address:
_____________________________________
_____________________________________
Phone:
_____________________________________
I am requesting a:
partial scholarship in the amount of _______
full scholarship in the amount of _________
for the following Stroke Survivor:
name: _______________________
annual income:____________________
for the following Caregiver/ Family Member(s):
name: ________________________
annual income:__________________
name: _______________________
annual income:__________________
name: _______________________
annual income:_________________
Reason the scholarship is needed:
Only a limited number of scholarships are available. Please send requests as soon as possible
for consideration.
Please return the scholarship application to:
Sheila Daley RN, BSN, MIS
Henry Ford Health System K-11 Neuroscience Institute
2799 W. Grand Blvd
Detroit, MI 48202
99019995
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