Instructions for application submission

  1. Please complete each section of the application. Additional sheets or attachments may be added if you wish.
  2. Do not staple your application together before sending.
  3. All elements of the application process are required. If any element is missing, you will be disqualified from consideration.
  4. You may either email your application to or mail to PO Box 8057, Louisville, KY 40257.
  5. Applications must be received by March 15.

Scholarship Application

Please Print or Type

Due on or before March 15

Student Background InformationDate of Application: _____/_____/______

Legal Name in Full______

FirstMiddleLast

Permanent Address______

NumberStreet

______

CityStateZip

Telephone(____)______E-mail: ______

Date of Birth_____/____/______

Name of Parent or Guardian______

Permanent Address______

NumberStreet

______

CityStateZip

Telephone(____)______E-mail: ______

Name of High School______

Address______

NumberStreet

______

CityStateZip

Projected Date of Graduation____/___/____

What is your cumulative high school GPA? ______on a ______scale.

Name of High School Counselor: ______

Phone Number: (___)______e-mail: ______

Educational Objective:

_____Associate Degree

______Four year Degree

______Vocational Certificate

Please explain your educational goals: ______

______

______

______

Names of institutions of higher learning where you have applied/been accepted:

______

______

______

______

______

List honors & achievements: List any honors or awards received for academic accomplishments. Include date received.

______

______

______

______

List major activities, sports and clubs: List activities in which you have participated. Include the name of the activity, offices held and dates participated.

______

______

______

Community Involvement & Volunteer Efforts: List community activities & volunteer work in which you have participated. Include the type of work, the name of the agency or organization & dates participated.

______

______

______

______

Jobs/Experience: List jobs or related experiences you have held, including the type of work, hours per week and dates.

______

______

______

______

Relate your experience with neurologic disease/brain injury.

______

______

______

______

______

______

______

______

Why should you receive funding from the Terrill Foundation, Inc.?

______

______

______

______

______

______

______

______

I give my permission for you to contact my guidance counselor or those who have written letters of recommendation on my behalf.

Signature:______

Students nameDate

Signature of Parent or guardian:

______

Date

Send applications to:

Or to

The Terrill Foundation, Inc

PO Box 8057

Louisville, KY 40257

Must be received no later than March 15

Recommendation Letter Form

To be completed by a personal reference not connected with the scholarship applicant’s school

Please discuss your reasons why the student deserves this scholarship. Describe the affect brain injury has had on the student. Describe any significant contributions made by the student through academics, public service or community involvement. Describe the student’s commitment to furthering his or her education.

This recommendation may be typed on the back of this form or on a separate sheet attached to this form.

Name of Student:______

FirstMiddle Last

Your name:______

FirstMiddle Last

Title:______

Address:______

NumberStreet

______

CityStateZip

Telephone:(______)______e-mail: ______

How long have you known the student? ______

In what capacity?______

______

______

Signature: ______Date: ______

Return this letter of reference to:

Or to

The Terrill Foundation, Inc

PO Box 8057

Louisville, KY 40257

Must be received no later than March 15.

Recommendation Letter Form

To be completed by a faculty member or administrator who has taught the scholarship applicant.

Please discuss your reasons why the student deserves this scholarship. Describe the affect brain injury has had on the student. Describe any significant contributions made by the student through academic public service or community involvement. Describe the student’s commitment to furthering his or her education.

This recommendation may be typed on the back of this form or on a separate sheet attached to this form.

Name of Student:______

FirstMiddle Last

Your name:______

FirstMiddle Last

Title:______

Address:______

NumberStreet

______

CityStateZip

Telephone:(______)______e-mail: ______

How long have you known the student? ______

In what capacity?______

______

______

Signature: ______Date: ______

Return this letter of reference to:

Or to

The Terrill Foundation, Inc

PO Box 8057

Louisville, KY 40257

Must be received no later than March 15

The Terrill Foundation, Inc: Student Application 1