HEADQUARTERS
1750 CLAIBORNE AVE.
SHREVEPORT, LA 71103
318.635.6471
FAX: 318.635.8901
WWW.LABLIND.COM
Scholarship Application for Academic Year 2016-17
Applicant's Full Legal Name:
Name of the high school from which you will graduate:
If you are already enrolled in a college or technical school, what is the name of
your college or technical school?
Parish in which Student Resides:
Certification:
By my signature, I certify that the information contained in this scholarship
application is true and correct to the best of my knowledge. I further
understand that, if awarded, the scholarship may be forfeited should it be
determined that false or fraudulent information was provided.
__________________________________
Student's Signature
__________________
Date
Important Dates:
April 30, 2015: Application deadline. This is a hard deadline for receipt at
Louisiana Association for the Blind. This is NOT a postmark date. Incomplete
applications and/or applications received after the deadline will not be
considered.
May 10, 2015: The scholarship awardee will be notified. All applicants will be
notified about the status of their application.
Mail completed application packet to:
LAB 2015 Scholarship Application Form
LAB Form #LVC-1
Louisiana Association for the Blind
Attn.: Libby Murphy
1750 Claiborne Avenue
Shreveport, LA 71103
Page 1 of 6
Rev. 03-30-15
HEADQUARTERS
1750 CLAIBORNE AVE.
SHREVEPORT, LA 71103
318.635.6471
FAX: 318.635.8901
WWW.LABLIND.COM
Scholarship Application
1. Applicant's Full Legal Name:
2. Street or P.O. Box Address:
3. City, State, Zip:
4. Parent/Guardian Name(s), if under 18 years old:
5. High School:
6. Date of Graduation or GED (mm/dd/yyyy):
7. Are you currently attending college or technical school?
Yes
No
8. If yes, please list school name:
9. Cumulative GPA:
10. SAT/ACT (if applicable):
11. List your School Extra-Curricular Activities and/or Community Service
(maximum 2,000 characters):
12. Major or intended field of study:
13. Honors/Awards received (maximum 2,000 characters):
14. Scholastic, professional, or civic societies to which you belong (maximum
2,000 characters):
15. Provide any additional information you believe may help the Scholarship
Selection Committee when considering your application (maximum 2,000
characters):
Required Supplemental Materials:
16. On a separate sheet of paper, please describe your educational and career
goals (minimum 250 words, maximum 500 words).
17. Attach official transcripts or GED certificate.
18. Attach a copy of the acceptance letter from your chosen accredited
college, university, technical or other accredited post-secondary institution.
19. Attach completed eye examination form signed by a physician.
20. Complete release statement authorizing review of eye exam, high school
transcripts, and application materials.
21. Please submit at least one letter of recommendation from a current
instructor. The statement can be general in nature, but should offer some
insight into the applicant's personality, study habits, and attitude.
LAB 2015 Scholarship Application Form
LAB Form #LVC-1
Page 2 of 6
Rev. 03-30-15
HEADQUARTERS
1750 CLAIBORNE AVE.
SHREVEPORT, LA 71103
318.635.6471
FAX: 318.635.8901
WWW.LABLIND.COM
Intended Use of Scholarship Funds
Applicant's Full Legal Name:
The primary purpose of the LAB scholarship is to offset expenses directly
associated with tuition, books, assistive devices, and adaptive technologies. In
the space below, please submit a budget that outlines your intended use of the
scholarship funds, if you are selected as a recipient.
PLEASE NOTE: As a condition of award, scholarship recipients must agree to
submit documentation of use of scholarship funds. At the end of each semester
or term, the awardee must provide LAB with a report of how funds were used to
advance his/her education, including an accounting of funds expended, with
supporting documentation (i.e., receipts).
Semester or Term
(For example: Fall,
Winter, Spring, Summer)
Description
(For example: Tuition, books,
electronic video magnifier,
Zoomtext, hand held magnifier, etc.)
TOTAL (cannot exceed $2,500.00)
LAB 2015 Scholarship Application Form
LAB Form #LVC-1
Estimated Expense
0
Page 3 of 6
Rev. 03-30-15
HEADQUARTERS
1750 CLAIBORNE AVE.
SHREVEPORT, LA 71103
318.635.6471
FAX: 318.635.8901
WWW.LABLIND.COM
Applicant's Full Legal Name:
Counselor's Certification
By my signature below, I certify the grade point average and test scores
reported on this application by the above-referenced student are true and
correct.
_____________________________________
Signature
__________________
Date
_____________________________________
Printed Name
__________________________
Phone Number
_____________________________________
Position
____________________________________
Email
_____________________________________
School
____________________________________
City
LAB 2015 Scholarship Application Form
LAB Form #LVC-1
Page 4 of 6
Rev. 03-30-15
HEADQUARTERS
1750 CLAIBORNE AVE.
SHREVEPORT, LA 71103
318.635.6471
FAX: 318.635.8901
WWW.LABLIND.COM
Applicant's Full Legal Name:
Information Release
By my signature, I authorize the LAB Scholarship Selection Committee to review
my eye exam, academic transcripts, and application materials.
_____________________________________
Student's Signature
_______________________
Date
If the applicant is under 18 years old, this form also must be signed by the
applicant's parent or guardian:
_____________________________________
Parent/Guardian Signature
________________________
Date
_____________________________________
Parent/Guardian Printed Name
LAB 2015 Scholarship Application Form
LAB Form #LVC-1
Page 5 of 6
Rev. 03-30-15
HEADQUARTERS
1750 CLAIBORNE AVE.
SHREVEPORT, LA 71103
318.635.6471
FAX: 318.635.8901
WWW.LABLIND.COM
Mandatory Eye Medical Information
Student's Legal Name:
Student's Address:
Visual Acuity with Best Correction:
Right Eye _____________________
Left Eye ____________________
Visual Fields (angle of widest diameter of field of vision):
Right Eye _____________________
Left Eye ____________________
The named individual is being considered for a scholarship for legally blind
individuals. Legally blind is defined as "an individual whose central visual acuity
does not exceed 20/200 in the better eye with correcting lenses, or whose visual
acuity if better than 20/200 is accompanied by a limit to the field of vision in the
better eye to such a degree that its widest diameter subtends an angle no
greater than 20 degrees."
Based on this definition, the visual function of the named individual is (check
one):
__________ Legally Blind
__________ Not Legally Blind
____________________________________
Signature of Examining Physician
_____________________
Date of Examination
____________________________________
Physician's Name Printed
___________________________________
City
LAB 2015 Scholarship Application Form
LAB Form #LVC-1
Page 6 of 6
Rev. 03-30-15