EmailMe Form - Michael Jon Barlin Scholarship Application

First Name *

Last Name *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

County *

Email *

Cell Phone *

### - ### - ####

Home Phone

### - ### - ####

College/University *

Major *

I confirm (to be eligible you have to meet ALL of these requirements) that I: *

am currently enrolled and attending college as an undergraduate

am a primary resident of Florida

have been diagnosed with systemic lupus erythrmatous (SLE)

have a minimum cumulative GPA of 2.5

How did you hear about us?

Additional requirements

Complete the application in full and include all required documents below (please adhere to all document requirements as your application will be withdrawn if all documents are not submitted) by August 31 via attachment or e-mail to: infose@lupus.org:

-Applicant must already be attending a four-year college or university and provide confirmation (PDF of Official Transcript or Unofficial Transcript, if mid-semester) of matriculation from the college. MUST BE AN UNDERGRADUATE STUDENT.
-Applicant must present a letter from his/her physician confirming a diagnosis of systemic lupus erythematosus.
-Applicant must provide proof (Driver's License, State ID or Passport) of PRIMARY residency in the State of Florida.
-Applicant must submit a one-page statement of how lupus has affected his/her college experience.

Transcript

Physician's note stating that you have been diagnosed with lupus

Proof of primary residency in Florida

One page statement of how lupus has affected his/her college experience