2009 ANNUAL SCHOLARSHIP AWARD FOR HIGH SCHOOL SENIORS WITH A HEARING LOSS

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1 ANNUAL SCHOLARSHIP AWARD FOR HIGH SCHOOL SENIORS WITH A HEARING LOSS The is pleased to announce a scholarship for high school seniors with a hearing loss, who are pursuing a college degree or vocational training. This scholarship is $1000 and will be awarded to each of two students residing in New Jersey. Recipients must have applied to a college or vocational education program, be between the ages of 17 and 20 and wear a hearing aid(s) or cochlear implants. Financial need is not a consideration. The scholarship is a one-time award. This scholarship is made possible in part by funds raised by the first Garden State Walk4Hearing event. The annual Walk4Hearing is a national project of the Hearing Loss Association of America to raise awareness about the causes and consequences of hearing loss, and to raise funds to provide information and support for people with hearing loss. Hearing Loss Association of America is a volunteer, international organization of people with hearing loss, their relatives, and friends. It is a non-profit, non-sectarian educational organization devoted to the welfare and interests of those who cannot hear well but are committed to participating in the hearing world. To apply for the scholarship, complete the 2009 SCHOLARSHIP APPLICATION FORM and send to: c/o Sandy Spekman, Scholarship Chair, HLA-NJ 328 Meadowbrook Lane South Orange, NJ Additional applications may be found online at:

2 2009 SCHOLARSHIP APPLICATION FORM (Instructions: Complete all parts from Section I through VI. Review checklist Section VII, page 4. Include three letters of reference, page 5.) Be sure to write YOUR NAME and name of your HIGH SCHOOL on each page of this application form, as well as on each page of your essay. 2 SECTION I: Applicant Data Name: (First) (Middle) (Last) Home address: Telephone number: address: Date of birth: Parent or guardian s name and address: Parent or guardian s daytime telephone number: Parent or guardian s signature Date SECTION II: High School Data Name, dates, and address(es) of high school(s) attended in the past four years: Telephone number(s): Name of most recent high school guidance counselor: Anticipated graduation date: SECTION III: College or Other Postsecondary School Data Name of college or other postsecondary school for which scholarship is requested: Address: Please check one: 4-year college 2-year college Community college Vocational school Other (Please explain) Enrolled: full time half time or more less than half time Acceptance status: accepted wait-listed don t know (Note: If you receive a letter of acceptance after you submit this application, or if your application status changes, please notify Sandy Spekman at or Sandy.Spekman@hearingloss-nj.org as soon as possible.)

3 SECTION IV: Personal Data 3 For each activity, please indicate the number of years participation and approximate number of hours spent on the activity per week. Extracurricular activities: Sports, intramurals: Community service: Employment or internship experience: Please list and give the dates of any awards, honors, and recognitions received in the last four years: SECTION V: Audiological Data How would you describe your hearing loss? Mild Moderate Severe Profound At what age was your hearing loss discovered? Do you wear a hearing aid(s) yes no If yes, do you wear one or two hearing aids? Do you have a cochlear implant(s) yes no If yes, do you have one or two cochlear implants? Do you use or require additional assistance in the classroom, such as notetakers, assistive listening devices, lecture transcripts, or C.A.R.T. (Computer Accessible Realtime Translation)? If so, please identify and explain: Do you use any special devices outside of school, such as a text pager or a closedcaptioning device? If so, please identify and explain: Note: Please attach your most recent audiogram and audiologist s report (measured within the last four years) with your completed application. SECTION VI: Essay

4 4 On a separate sheet of paper, please write a short essay (approximately 500 words) on the topic: HOW HEARING LOSS HAS IMPACTED MY LIFE (AND HOW I HAVE MET THOSE CHALLENGES) Please describe the impact of hearing loss on your life academically, emotionally, and socially. How have you met those challenges? In addition to your own efforts, tell us about other people who may have helped you, as well as any assistive technology. Include details about your career goals, which you have summarized on the application form, and your educational plan for achieving these goals. Please print or type your essay and write your name and name of your high school on each page of the essay as well as on the application form Include your essay with your application. SECTION VII: Checklist for completed applications Eligibility: Applicants must be between the ages of 17 and 20, and entering their first year of college or other postsecondary school; and, must have a documented hearing loss in one or both ears. Deadline for submission of application: May 1, 2009 and must include: The completed application form A copy of your most recent audiogram (within the last four years) and audiologist s report Essay as indicated in SECTION VI A copy of your high school transcript Three letters of reference (Please make two additional copies of the last page in the application packet.) Note: Two letters of reference must be from a high school teacher or guidance counselor; the third must be from an unrelated adult who knows the candidate well (e.g. teacher, coach, religious leader, Scout leader, etc.) Please send the completed application forms to: c/o Sandy Spekman, Scholarship Chair, HLA-NJ 328 Meadowbrook Lane South Orange, NJ 07079

5 5 LETTER OF REFERENCE FOR HLAA SCHOLARSHIP Applicant s name and address: Evaluator s name and address: Relationship of evaluator to applicant: (teacher, employer, etc.) How long and under what circumstances have you known the applicant? Please comment on the candidate s academic strengths and weaknesses, social and emotional maturity, and also describe the qualities of the applicant which you believe will enable him/her to succeed in college or vocational training. (You may use the back of this form, or attach a separate sheet.) For the Evaluator: Hearing Loss Association of America (HLAA) is a volunteer, international organization of people with hearing loss, their relatives, and friends. It is a non-profit, non-sectarian educational organization devoted to the welfare and interests of those who cannot hear well but are committed to participating in the hearing world. HLA NJ is awarding this scholarship in the amount of $1000 to a deserving student with hearing loss from New Jersey that is entering his or her first year of college or vocational training. Please return this evaluation letter to the applicant. It will be included with his/her application. If you have any questions, you may call Sandy Spekman at or Sandy.Spekman@hearingloss-nj.org. Additional applications may be found online at: Thank you for taking the time to complete this evaluation; your input is appreciated.