7/27/2019 Anne Ford Scholarship 20122013
1/16
The Anne Ford Scholarship
Use this scholarship application only if:
- You are a graduating high school senior (Class of 2013)- You have a documented learning disability- You are planning to attend a 4 year college or university starting in the Fall of 2013
7/27/2019 Anne Ford Scholarship 20122013
2/16
1 2012-2013 Application Information
The National Center for Learning Disabilities is seeking
applicants for the 2012-2013 Anne Ford Scholarship. The
Anne Ford Scholarship is a $10,000 ($2,500/year over four
years) award granted to a graduating high school senior
with a documented learning disability who will be enrolled,
in the fall of 2012, in a full-time bachelors degree
program.
The ideal Anne Ford Scholar is a student who:
Articulates his/her LD and clearly demonstratesthe importance of self-advocacy
Is committed to completing a four-year collegedegree and has begun to set realistic career goals
Plans to contribute to society in ways that increaseopportunities for individuals with LD
Excels as a role model and spokesperson for otherswho struggle with LD
Demonstrates financial needEligibility & Selection Criteria
To be eligible for the 2012-2013 Anne Ford Scholarship,
an applicant must:
Have an overall Grade Point Average (GPA) of 3.0or higher on a 4 point scale (or equivalent)
Demonstrate financial need Provide most current documentation of an
identified learning disability (Please Note: AD/HD
alone is not considered a learning disability; eligible
candidates must also provide documentation of a
specific learning disability.)
Be a U.S. citizenPlease Note: If you will be attending a two-year communitycollege, vocational or technical training program, or
specialized program for students with LD, you are not
eligible for the Anne Ford Scholarship. Please visit our
website atwww.LD.orgfor more information on the
Allegra Ford Thomas Scholarship.You may not apply to
both scholarships.
Mentoring & OutreachOpportunities
The Anne Ford Scholar must be willing to mentor future
Scholars and act as a role model for individuals with
learning disabilities through such activities as public
speaking, writing for publications, and engaging in other
opportunities made possible through NCLD.
Scholarship Requirements
Scholars are required to submit annual updates detailing
their progress in school and offering insights about theiracademic and personal growth. The $10,000 scholarship
will be paid in four yearly installments of $2,500. Scholars
must first submit proof of course registration to receive
their first installment. To continue receiving payments
scholars must provide proof of course registration for each
ensuing semester and documentation of passing grades
(transcripts).
Selection ProcessThe Anne Ford Scholarship Committee, comprised of
members of NCLDs Board of Directors, Professional
Advisory Board, and distinguished friends, will make the
final selection of scholars in Spring 2013.
Submitting Your Application
Please use the Application Requirements Checklist to make
sure that all needed materials are included in thescholarship packet. All required materials must be received
in one packet.
Questions?
First, please check out theFrequently Asked Questionson
our website. If your question is not answered there, you
may contact us.
Email:[email protected]
Phone: (888) 575-7373
http://www.ld.org/http://www.ld.org/http://www.ld.org/http://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqhttp://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqhttp://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqmailto:[email protected]:[email protected]:[email protected]:[email protected]://www.ncld.org/about-us/learning-disability-scholarships-awards/anne-ford-allegra-ford-scholarships-faqhttp://www.ld.org/7/27/2019 Anne Ford Scholarship 20122013
3/16
2 Application Requirements Checklist
The Anne Ford Scholarship is for graduating high school seniors who will be attending a four-year, bachelors degree
program in the fall.If you are planning to attend community college, vocational or technical school, or a specialized program for
students with LD, please visit us atwww.LD.orgto apply for the Allegra Ford Thomas Scholarship.
Do not apply to both the Anne Ford Scholarship and the Allegra Ford Thomas Scholarship.
Use this checklist to keep track of items needed for the Anne Ford Scholarship Application.
Please be sure that you return the following items in your packet:
Basic Information Form Personal Achievements & Activities Form A personal statement (see Personal Statement page for details) High school transcript (official or unofficial) Three (3) letters of recommendation (at least one from a teacher) Financial Statement Form SAT, ACT, or other standardized test scores (unofficial copies acceptable) Most recent documentation of a learning disability
Submit all of these materials IN ONE PACKET to:
National Center for Learning Disabilities
c/o Anne Ford Scholarship
381 Park Avenue South, Suite 1401New York, NY 10016
Applications MUST be postmarked byDecember 31, 2012.
Please note that any materials submitted as part of the application process will not be returned.
http://www.ld.org/http://www.ld.org/http://www.ld.org/http://www.ld.org/7/27/2019 Anne Ford Scholarship 20122013
4/16
3 Basic Information FormPlease write legibly or type in your answers.
APPLICANT INFORMATION PARENT/GUARDIAN INFORMATION
Applicant Name:
Last First Middle
Parent/Guardian Name(s):
Date of Birth: / /
Month Day Year
Mailing Address (if different from applicant):
Mailing Address: City: State: Zip Code:
City: State: Zip Code: Parent/Guardian Home Phone (if different from applicant):
Home Phone: Cell Phone: Parent/Guardian Cell Phone:
Applicant Email Address (Use block letters):
@. Yes, I would like to subscribe to NCLD email updates, newsletters, and alerts.
Parent/Guardian Email Address (Use block letters):
@. Yes, I would like to subscribe to NCLD email updates, newsletters, and alerts.
Are you a United States Citizen?* Yes No
*Applicants must be current U.S. citizens. If you have questions about your eligibility
for this award, send your inquiry [email protected].
What is your relationship to the applicant? (Check all that apply)
Parent Legal Guardian Other Relative (specify): ___________
Other (specify): __________________
mailto:[email protected]:[email protected]:[email protected]:[email protected]7/27/2019 Anne Ford Scholarship 20122013
5/16
SCHOOL HISTORY
High School(s):
Name of School City/State Years Attended
Middle School (s):
Name of School City/State Years Attended
Primary/Elementary School(s):
Name of School City/State Years Attended
How did you hear about the Anne Ford Scholarship? Family School Website (please specify): ____________________
Other (please explain): __________________________________________________________
LEARNING DISABILITY INFORMATION
Please check which of these learning disabilities you have.
Basic Reading Skills (Dyslexia) Listening Comprehension (and processing) Executive Functioning/Organization Skills
Reading Fluency Skills (Dyslexia) Written Expression (Dysgraphia) Non-verbal LD
Spelling Math Calculation (Dyscalculia) Other (please explain):
_____________________________________ Reading Comprehension (Dyslexia) Math Problem Solving (Dyscalculia)
Date of Initial Diagnosis/Classification: ________________________________ Date of Most Recent Testing: __________________________________
7/27/2019 Anne Ford Scholarship 20122013
6/16
(Please Note: In order to be eligible for the Anne Ford Scholarship, applicants must have documentation of a specific learning disability, such as dyslexia, dyscalculia,
dysgraphia, etc. Conditions including AD/HD, Aspergers Syndrome and other autism spectrum disorders, Cerebral Palsy, and psychiatric conditions do not alone qualify a
student for this scholarship. Applicants with these conditions are welcome to apply but must also provide documentation of a specific learning disability.)
OPTIONAL SELF-IDENTIFICATION
African-American/Black (not of Hispanic origin) American Indian or Alaskan Native
Asian or Pacific Islander (includes Indian subcontinent) Hispanic/Latino (Spanish culture or origin, regardless of race)
White (persons not of Hispanic origin, having origin in any of the
original peoples of Europe, North Africa, or the Middle East)
Race not included above (Please specify):_________________________________________________________
CERTIFICATION AND AUTHORIZATION
Certification:All of the information provided on this form is true and complete to the best of my knowledge. I certify that I have a documented learning disabil
will be earning my high school diploma or its equivalent, and will be enrolling for the first time in a full-time bachelors degree program in the 2013-2014
academic year. I hereby authorize the National Center for Learning Disabilities (NCLD) to use my personal statement, in whole or in part, as well as non-
financial information from my application for publicity and public relations purposes. I understand that information contained in my application may be used fo
research and/or publicity related activities. All application materials including essays and transcripts become property of NCLD.
Authorization for Release of Information/Records:Applicants are responsible to arrange for transcripts and other required documentation to be submitted to
NCLD. In the event that NCLD finds it necessary to seek additional information, permission is hereby given to NCLD and its designees to contact school
officials and others to request additional relevant information for use by the Anne Ford Scholarship Selection Committee and/or NCLD staff.
Signature of Applicant: _______________________________________________________ Date: _________________________
Signature of Parent or Guardian: _______________________________________________ Date: _________________________
(required if applicant is under 18)
7/27/2019 Anne Ford Scholarship 20122013
7/16
4 Personal Achievements & Activities FormName: __________________________________________________________________ Date of Birth: _____ / _____ / _____
Last First Middle Month Date Year
PART 1: ACADEMIC INFORMATION
Grades: You MUST submit a copy of your transcript. Grade Point Average (GPA): ________ on scale of ________
Class Rank (if available): ________ out of ________
Standardized Testing: You must submit either SAT or ACT scores.
SAT: Exam Date: _____ / _____ / _____
Best Score: Math ____ Critical Reading ____ Writing ____
ACT: Exam Date: _____ / _____ / _____
Best Score: Composite _____
Are you planning to take either test again? Yes No
If you have taken any other standardized tests (AP, IB, SAT Subject, etc.) and would like to share your scores, please do so below:
_____________________________________________________________________________________________________________________
PART 2: EXTRACURRICULAR ACTIVITIES
List extracurricular activities (school clubs, sports, etc.) you have been involved in. If you need more room, you may attach another piece of paper.
Activity Grades Involved(all that apply)
Hours per Week Summer or School Year( all that apply)
Position Held, Awards/Honors, Other Achievements
9 11
10 12
Summer
School Year
9 11
10 12
Summer
School Year
9 11
10 12
Summer
School Year
7/27/2019 Anne Ford Scholarship 20122013
8/16
PART 3: COMMUNITY AND WORK EXPERIENCE
List anycommunity, volunteer, or work experience you have. If you need more room, you may attach another piece of paper.
Activity Grades Involved
(all that apply)
Hours per Week Summer or School Year
( all that apply)
Position Held, Awards/Honors, Other Achievements
9 11
10 12
Summer
School Year
9 11
10 12
Summer
School Year
9 11
10 12
Summer
School Year
PART 4: OTHER ACTIVITIES
List any other activities you have been involved in. If you need more room, you may attach another piece of paper.
Activity Grades Involved
(all that apply)
Hours per Week Summer or School Year
( all that apply)
Position Held, Awards/Honors, Other Achievements
9 11
10 12
Summer
School Year
9 11
10 12
Summer
School Year
9 11
10 12
Summer
School Year
PART 5: SPECIAL INTERESTS, HONORS, AND AWARDS
Do you have any additional special interests or hobbies? If so, explain: ____________________________________________________________________
_____________________________________________________________________________________________________________________________
Since the 9th grade, have you received any special awards or honors? If so, list them: ___________________________________________________________
______________________________________________________________________________________________________________________________
Feel free to submit any additional information or a resume as part of this application.
7/27/2019 Anne Ford Scholarship 20122013
9/16
5 Personal Statement
Please pay special attention to this part of the application. Together with information provided in letters
of recommendation the personal statement is the best way for members of the review committee to get to
know you and understand your journey as a student with LD.
This personal statement should describe your frustrations and triumphs in dealing with your specific
learning disability. Feel free to express yourself in creative ways! Be sure that you share how you embody
the characteristics of an ideal candidate as described in the introduction to the application. Your
statement should make specific mention of how you believe a college education will enhance your life and
how the Anne Ford Scholarship will help you achieve this goal.
Here are some key questions to think about as you write:
Tell us about your learning disability. How it has affected you in school, at home, and in thecommunity?
What are some examples of times you were able to overcome specific barriers to learning? Who are the people in school, at home, or in the community who have helped you most? What accommodations or assistive technologies have helped you succeed? What do you want to study in college and why? How would the Anne Ford Scholarship help you accomplish your goals?
Submit your personal statement as a written, typed essay of 750-1000 words.
7/27/2019 Anne Ford Scholarship 20122013
10/16
The Anne Ford Scholarship
Recommendation Form
All applications must be postmarked byDecember 31, 2012. Please return this form and any additional documentation to
the student so it can be included in the completed application packet.
Name of Applicant: ________________________________ Applicant Date of Birth: _____ / _____ / _____
The Anne Ford Scholarship is a $10,000 award given to a high school senior with a documented learning disability who
will be enrolled in a full time bachelors degree program in the fall of 2013.
The ideal Anne Ford Scholar is a student who:
Has faced the challenges of having a learning disability (LD) with perseverance Is committed to completing a college degree and setting career goals Embraces new opportunities Has a well-rounded perspective shaped by experiences at school and in the community Understands how LD affects his or her life and recognizes the importance of self-advocacy Believes in contributing to society in ways that increase the potential ofallpeople with LD Would welcome opportunities to serve as a role model and spokesperson for others with LD
INSTRUCTIONS
Step 1: Please provide the following information about yourself.
Name: Title:
School/Organization:
Mailing Address:
Telephone: ( ) - ext. Email:
How do you know the applicant?
How long have you known the applicant?
7/27/2019 Anne Ford Scholarship 20122013
11/16
Step 2: Please complete the rating scale below.
Below
Average
Average Above
Average
Well Above
Average
Outstanding I Dont
Know
Academic Achievement
College Readiness
Perseverance
Motivation
Self-advocacy
Understanding of LD
Leadership and Initiative
Involvement in school/community
activities
Role model/spokesperson for people
with LD
Use of accommodations & supports
Step 3: Please answer the following questions on a separate piece of paper.
1. Is this student an effective self-advocate? Explain.2. How has this student reacted to setbacks or persevered in difficult situations? Please give examples if possible.3. How well does this student understand his/her LD? Explain.4. What are the three characteristics you most appreciate about this student?
Feel free to provide additional feedback about this student in your response.
Please return this form and completed additional pages to the student.
7/27/2019 Anne Ford Scholarship 20122013
12/16
The Anne Ford Scholarship
Recommendation Form
All applications must be postmarked byDecember 31, 2012. Please return this form and any additional documentation to
the student so it can be included in the completed application packet.
Name of Applicant: ________________________________ Applicant Date of Birth: _____ / _____ / _____
The Anne Ford Scholarship is a $10,000 award given to a high school senior with a documented learning disability who
will be enrolled in a full time bachelors degree program in the fall of 2013.
The ideal Anne Ford Scholar is a student who:
Has faced the challenges of having a learning disability (LD) with perseverance Is committed to completing a college degree and setting career goals Embraces new opportunities Has a well-rounded perspective shaped by experiences at school and in the community Understands how LD affects his or her life and recognizes the importance of self-advocacy Believes in contributing to society in ways that increase the potential ofallpeople with LD Would welcome opportunities to serve as a role model and spokesperson for others with LD
INSTRUCTIONS
Step 1: Please provide the following information about yourself.
Name: Title:
School/Organization:
Mailing Address:
Telephone: ( ) - ext. Email:
How do you know the applicant?
How long have you known the applicant?
7/27/2019 Anne Ford Scholarship 20122013
13/16
Step 2: Please complete the rating scale below.
Below
Average
Average Above
Average
Well Above
Average
Outstanding I Dont
Know
Academic Achievement
College Readiness
Perseverance
Motivation
Self-advocacy
Understanding of LD
Leadership and Initiative
Involvement in school/community
activities
Role model/spokesperson for people
with LD
Use of accommodations & supports
Step 3: Please answer the following questions on a separate piece of paper.
1. Is this student an effective self-advocate? Explain.2. How has this student reacted to setbacks or persevered in difficult situations? Please give examples if possible.3. How well does this student understand his/her LD? Explain.4. What are the three characteristics you most appreciate about this student?
Feel free to provide additional feedback about this student in your response.
Please return this completed form and additional pages to the student.
7/27/2019 Anne Ford Scholarship 20122013
14/16
The Anne Ford Scholarship
Recommendation Form
All applications must be postmarked byDecember 31, 2012. Please return this form and any additional documentation to
the student so it can be included in the completed application packet.
Name of Applicant: ________________________________ Applicant Date of Birth: _____ / _____ / _____
The Anne Ford Scholarship is a $10,000 award given to a high school senior with a documented learning disability who
will be enrolled in a full time bachelors degree program in the fall of 2013.
The ideal Anne Ford Scholar is a student who:
Has faced the challenges of having a learning disability (LD) with perseverance Is committed to completing a college degree and setting career goals Embraces new opportunities Has a well-rounded perspective shaped by experiences at school and in the community Understands how LD affects his or her life and recognizes the importance of self-advocacy Believes in contributing to society in ways that increase the potential ofallpeople with LD Would welcome opportunities to serve as a role model and spokesperson for others with LD
INSTRUCTIONS
Step 1: Please provide the following information about yourself.
Name: Title:
School/Organization:
Mailing Address:
Telephone: ( ) - ext. Email:
How do you know the applicant?
How long have you known the applicant?
7/27/2019 Anne Ford Scholarship 20122013
15/16
Step 2: Please complete the rating scale below.
Below
Average
Average Above
Average
Well Above
Average
Outstanding I Dont
Know
Academic Achievement
College Readiness
Perseverance
Motivation
Self-advocacy
Understanding of LD
Leadership and Initiative
Involvement in school/community
activities
Role model/spokesperson for people
with LD
Use of accommodations & supports
Step 3: Please answer the following questions on a separate piece of paper.
1. Is this student an effective self-advocate? Explain.2. How has this student reacted to setbacks or persevered in difficult situations? Please give examples if possible.3. How well does this student understand his/her LD? Explain.4. What are the three characteristics you most appreciate about this student?
Feel free to provide additional feedback about this student in your response.
Please return this completed form and additional pages to the student.
7/27/2019 Anne Ford Scholarship 20122013
16/16
6 Financial StatementTo be filled out by the applicants parent(s) or legal guardian.
Completed application packet must be postmarked no later than December 31, 2012.
Name of Applicant: ____________________________________ Applicants Date of Birth: _____ / _____ / _____
STATEMENT OF INCOME (Please select an option below.)
Option 1:
Total income as reported on households (applicantand parent/guardian) most recent federal income
tax return: $ _______________________
(IRS form 1040, Line 7)
Total number of exemptions claimed: ________
Option 2:
Individual income reported by:
Father $_________ Mother $________ Student $________ Other $_________
List all members of the household, ages, and relationship to the applicant:
Name Age Relationship Name Age Relationship
Is this a single parent family? Yes No Number of dependent children in the family: _____
Number of dependent children currently attending college: _____
Planned year(s) of graduation: ____________________________
Number of dependent children currently attending high school: _____
Planned year(s) of graduation: ____________________________
COLLEGE INFORMATION
Names of colleges to which applicant applied Accepted (circle one) Expected Annual Tuition Costs
Yes Pending
Yes Pending
Yes Pending
Yes Pending
Yes Pending
Those candidates chosen for final review by the Selection Committee will be asked to submit copies of the most recent
Federal income tax returns and/or W-2 forms. Please attach any additional information you would like to share regarding
your financial situation.