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

2012-2013 Application Information

Mentoring & Outreach Opportunities
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.

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 demonstrates the importance of self-advocacy Is committed to completing a four-year college degree and has begun to set realistic career goals Plans to contribute to society in ways that increase opportunities for individuals with LD Excels as a role model and spokesperson for others who struggle with LD Demonstrates financial need

Scholarship Requirements
Scholars are required to submit annual updates detailing their progress in school and offering insights about their academic 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).

Eligibility & Selection Criteria

To be eligible for the 2012-2013 Anne Ford Scholarship, an applicant must: Have an overall Grade Point Average (GPA) of 3.0 or 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. citizen Please Note: If you will be attending a two-year community college, 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 at www.LD.org for more information on the Allegra Ford Thomas Scholarship. You may not apply to both scholarships.

Selection Process
The 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 the scholarship packet. All required materials must be received in one packet.

Questions?
First, please check out the Frequently Asked Questions on our website. If your question is not answered there, you may contact us. Email: AFScholarship@ncld.org Phone: (888) 575-7373

Application Requirements Checklist

The Anne Ford Scholarship is for graduating high school seniors who will be attending a four-year, bachelors degree students with LD, please visit us at www.LD.org to apply for the Allegra Ford Thomas Scholarship.

program in the fall. If you are planning to attend community college, vocational or technical school, or a specialized program for

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) Three (3) letters of recommendation (at least one from a teacher) High school transcript (official or unofficial)

SAT, ACT, or other standardized test scores (unofficial copies acceptable) Most recent documentation of a learning disability

Financial Statement Form

Submit all of these materials IN ONE PACKET to:

National Center for Learning Disabilities 381 Park Avenue South, Suite 1401 New York, NY 10016 c/o Anne Ford Scholarship

Applications MUST be postmarked by December 31, 2012. Please note that any materials submitted as part of the application process will not be returned.

Basic Information Form

PARENT/GUARDIAN INFORMATION
Parent/Guardian Name(s): Last First / Day / Middle Year Mailing Address (if different from applicant): City: State: Cell Phone: Zip Code: State: Zip Code:

Please write legibly or type in your answers.

APPLICANT INFORMATION
Applicant Name:

Date of Birth: Mailing Address: City: Home Phone:

Month

Parent/Guardian Home Phone (if different from applicant): Parent/Guardian Cell Phone: Parent/Guardian Email Address (Use block letters):

@.
Yes, I would like to subscribe to NCLD email updates, newsletters, and alerts.

Applicant Email Address (Use block letters):

@.
Yes, I would like to subscribe to NCLD email updates, newsletters, and alerts.

Are you a United States Citizen?*

*Applicants must be current U.S. citizens. If you have questions about your eligibility for this award, send your inquiry to AFScholarship@ncld.org.

Yes

No

What is your relationship to the applicant? (Check all that apply) Other (specify): __________________ Parent Legal Guardian

Other Relative (specify): _____________

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?

Other (please explain): __________________________________________________________

Family

School

Website (please specify): ____________________

LEARNING DISABILITY INFORMATION

Please check which of these learning disabilities you have. Reading Fluency Skills (Dyslexia) Basic Reading Skills (Dyslexia)

Date of Initial Diagnosis/Classification: ________________________________

Reading Comprehension (Dyslexia)

Spelling

Math Problem Solving (Dyscalculia)

Math Calculation (Dyscalculia)

Written Expression (Dysgraphia)

Listening Comprehension (and processing)

Other (please explain):

Non-verbal LD

Executive Functioning/Organization Skills

Date of Most Recent Testing: __________________________________

______________________________________

student for this scholarship. Applicants with these conditions are welcome to apply but must also provide documentation of a specific learning disability.)

dysgraphia, etc. Conditions including AD/HD, Aspergers Syndrome and other autism spectrum disorders, Cerebral Palsy, and psychiatric conditions do not alone qualify a

(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,

OPTIONAL SELF-IDENTIFICATION
African-American/Black (not of Hispanic origin) Asian or Pacific Islander (includes Indian subcontinent) White (persons not of Hispanic origin, having origin in any of the original peoples of Europe, North Africa, or the Middle East) American Indian or Alaskan Native Hispanic/Latino (Spanish culture or origin, regardless of race) 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 disability,

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 nonresearch and/or publicity related activities. All application materials including essays and transcripts become property of NCLD.

financial information from my application for publicity and public relations purposes. I understand that information contained in my application may be used for

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: _______________________________________________________ Signature of Parent or Guardian: _______________________________________________
(required if applicant is under 18)

Date: _________________________ Date: _________________________

4
Grades:

Personal Achievements & Activities Form

Last First Middle

Name: __________________________________________________________________

Date of Birth: _____ / _____ / _____

Month Date Year

PART 1: ACADEMIC INFORMATION

Class Rank (if available): ________ out of ________ You must submit either SAT or ACT scores.

You MUST submit a copy of your transcript.

Grade Point Average (GPA): ________ on scale of ________

Standardized Testing: SAT:

If you have taken any other standardized tests (AP, IB, SAT Subject, etc.) and would like to share your scores, please do so below:

Are you planning to take either test again?

Best Score: Math ____ Critical Reading ____ Writing ____ Yes No

Exam Date: _____ / _____ / _____

ACT: Exam Date: _____ / _____ / _____ Best Score: Composite _____

_____________________________________________________________________________________________________________________

PART 2: EXTRACURRICULAR ACTIVITIES

Activity Grades Involved (all that apply)

List extracurricular activities (school clubs, sports, etc.) you have been involved in. If you need more room, you may attach another piece of paper.
Hours per Week Summer or School Year ( all that apply) Position Held, Awards/Honors, Other Achievements

9 9 9

10 10 10

12 12 12 11 11

11

Summer Summer Summer

School Year School Year School Year

PART 3: COMMUNITY AND WORK EXPERIENCE

Activity Grades Involved (all that apply)

List any community, volunteer, or work experience you have. If you need more room, you may attach another piece of paper.
Hours per Week Summer or School Year ( all that apply) Position Held, Awards/Honors, Other Achievements

9 9 9

10 10 10

12 12 12 11 11

11

Summer Summer Summer

School Year School Year School Year

PART 4: OTHER ACTIVITIES

Activity

List any other activities you have been involved in. If you need more room, you may attach another piece of paper.
Grades Involved (all that apply) Hours per Week Summer or School Year ( all that apply) Position Held, Awards/Honors, Other Achievements

9 9 9

10 10 10

12 12 12 11 11

11

Summer Summer Summer

School Year School Year 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.

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 the community? 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.

The Anne Ford Scholarship

Recommendation Form
All applications must be postmarked by December 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 of all people 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: School/Organization: Mailing Address: Telephone: ( ) ext. Email: Title:

How do you know the applicant? How long have you known the applicant?

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. 4. What are the three characteristics you most appreciate about this student? Feel free to provide additional feedback about this student in your response. 3. How well does this student understand his/her LD? Explain.

Please return this form and completed additional pages to the student.

The Anne Ford Scholarship

Recommendation Form
All applications must be postmarked by December 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 of all people 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: School/Organization: Mailing Address: Telephone: ( ) ext. Email: Title:

How do you know the applicant? How long have you known the applicant?

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. 4. What are the three characteristics you most appreciate about this student? Feel free to provide additional feedback about this student in your response. 3. How well does this student understand his/her LD? Explain.

Please return this completed form and additional pages to the student.

The Anne Ford Scholarship

Recommendation Form
All applications must be postmarked by December 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 of all people 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: School/Organization: Mailing Address: Telephone: ( ) ext. Email: Title:

How do you know the applicant? How long have you known the applicant?

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. 4. What are the three characteristics you most appreciate about this student? Feel free to provide additional feedback about this student in your response. 3. How well does this student understand his/her LD? Explain.

Please return this completed form and additional pages to the student.

Financial Statement
Completed application packet must be postmarked no later than December 31, 2012. To be filled out by the applicants parent(s) or legal guardian.

Name of Applicant: ____________________________________ STATEMENT OF INCOME (Please select an option below.) Option 1: Total income as reported on households (applicant and parent/guardian) most recent federal income tax return: $ _______________________ (IRS form 1040, Line 7)

Applicants Date of Birth: _____ / _____ / _____

Option 2:

Individual income reported by:

Father $_________ Mother $________ Student $________ Other $_________

Total number of exemptions claimed: ________

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

Number of dependent children currently attending college: _____

No

Number of dependent children in the family: _____

Number of dependent children currently attending high school: _____ Planned year(s) of graduation: ____________________________

Planned year(s) of graduation: ____________________________

COLLEGE INFORMATION
Names of colleges to which applicant applied Accepted (circle one) Expected Annual Tuition Costs

Yes Yes Yes Yes Yes

Pending Pending Pending Pending Pending

Those candidates chosen for final review by the Selection Committee will be asked to submit copies of the most recent your financial situation.

Federal income tax returns and/or W-2 forms. Please attach any additional information you would like to share regarding