SBWIS Educational Scholarship
In Memory of Mary Ann Potts, Ph.D.
Applications must be received by Friday, May 1, 2015!
The Spina Bifida Wisconsin, Ltd. Scholarship Fund was established in 1996 to enhance opportunities for persons born
with Spina Bifida to achieve their full potential through the pursuit of higher education including college, graduate
school or trade school. The Scholarship Fund offers assistance for such necessities as tuition, books, room and board,
transportation and specialized equipment needs.
Criteria:
 Applicant must have Spina Bifida.
 There is no age limitation for applicants.
 Applicants must have an updated SBWIS data form on file with the SBWIS Office by the application deadline.
 Applicant must be a high school graduate or possess a G.E.D. or equivalent before scholarship is awarded.
 Applicant must be enrolled or accepted by an accredited college, junior college, or university; an accredited trade
school or vocational training program and plan to attend in the fall of the same year as the application.
The Spina Bifida Wisconsin, Ltd. Scholarship Fund is administered under the following guidelines:
 Applications must be received by the SBWIS Office by May 1st to be considered for the following school year.
 Scholarship awards are based on academic record, community service, work history and leadership.
 Race, religion, and gender will not be considered when evaluating and rating scholarship applications.
 A limited number of scholarships are awarded each year dependent on available funds. The total number is
approved by the SBWIS Board of Directors.
 Students who have been awarded the scholarship in the past will be eligible to receive the scholarship in
subsequent years, but priority will go to students who have not yet received a scholarship. This should not
dissuade students from re-applying as some years there are no scholarship applicants.
 Funds will be paid directly to the school except in those cases where provisions have been made for other
resources (such as the Division of Vocational Rehabilitation) to cover tuition, or the Board of Directors
determines that special circumstances warrant the waiver of this stipulation.
The SBWIS Board of Directors determines who scholarships are awarded to. You will be notified of the Board’s
decision by June 2. Board members and their dependents are not eligible for the scholarship.
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SBWIS Educational Scholarship In Memory of Mary Ann Potts, Ph.D.
Scholarship Application
Name
Date of Birth
Address
City
State
Zip
Phone
Father’s/Guardian’s Name
Occupation
Mother’s/Guardian’s Name
Occupation
Spouse’s Name
Occupation
Age
(
)
Name and address of school/college you will attend ________________________________________________________
__________________________________________________________________________________________________
What will be the total cost of your education for the upcoming school year? _____________________________________
__________________________________________________________________________________________________
How do you expect to finance your college or vocational education? ___________________________________________
__________________________________________________________________________________________________
Have you received this scholarship previously?
YES
NO
If yes, when? _____________________________
__________________________________________________________________________________________________
List any full- or part-time jobs presently or previously held:
Employer
Position/Job Title
Immediate Supervisor
Dates employed
1. _______________________________________________________________________________________________
2. _______________________________________________________________________________________________
3. _______________________________________________________________________________________________
Add any other information that you think is pertinent to this application: _______________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
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This scholarship is made possible through memorial donations from family, friends and colleagues of Mary Ann Potts, Ph.D. Please
sign below if you are willing to let SBWIS send a brief biography of you to the Potts Family if you are awarded this scholarship.
This bio will include your educational and career goals, the school you plan on attending and other pertinent information.
Signature
Date
Information needed for scholarship payment:
Name of institution of higher learning: __________________________________________________________________
Institution’s address where the scholarship payment should be sent (usually the Bursar’s Office): ___________________
_________________________________________________________________________________________________
Contact Name and Phone Number: _____________________________________________________________________
Your social security or student ID Number: ______________________________________________________________
Your application must be accompanied by the following:
(Check each box to indicate that you have included the appropriate documents)
 This application




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Copy of high school transcript or current college transcript
Letter verifying admission to a school/college/university/employment training program
Reference letters from one school faculty member/teacher and one personal reference (not a family member)
Statement of disability from a physician (including name, address, and phone number of physician)
Personal statement explaining goals and what you want to accomplish with education/training you will receive. Describe
any accomplishments or contributions of which you are most proud - these can be school, extracurricular, church,
community or other activities. Please limit this statement to two (2) pages or less.
 All submissions will be strictly confidential.
 Applications will be considered only if completed in full and submitted by mail with all the documents mentioned
above.
 Applications must be received by May 2nd at:
Spina Bifida Wisconsin, Ltd.
830 North 109th Street, Suite 6,
Wauwatosa, WI 53226
 Please contact the SBWIS Office at 414-607-9061 or sbwis@sbwis.org if you have any questions.
You will be notified of the Board’s decision by June 2nd…Good Luck!!!
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