Als ride For Life Presents: Scholarship Announcement for Students Impacted by als



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Scholarship Chair


ALS Ride For Life

Ride For Life is a 501 ( c ) 3, IRS recognized charity; www.ALSRideForLife.org

Essay: In the area below affix your print out. Do not exceed this one page. Additional and loose pages will be discarded.
Explain how ALS has affected your family. Relate who the patient is and your interaction, if any, with them. Include any fundraising or awareness activities or any involvement with ALS advocacy that you may have had. Why do you think you should be selected for this scholarship?

Applicant Signature Date


Parent Signature
Counselor Signature Email

ALS Ride For Life Scholarship Application


Made possible by teacher unions and business donations.

Please fill out the application below and submit by deadline. Make all entries printed, neat and legible.

Applicant Name


Last First

Address


Street
Town State Zip

Evening Phone Number

Area Code Number E-Mail Address
High School Name

Address


Street
Town State Zip
HS Counselor Phone Email

ALS Relationship: Check one


Child of a patient Grandchild of a patient Niece/Nephew of patient Sibling of a patient
Patient Name

Patient Address

Street

Town State Zip

How did you hear about the scholarship?


Forms must be postmarked no later than February 13, 2017

Christine Pendergast

18 Grandview Blvd.


Miller Place, NY 11764
All decisions are final and are the discretion of the Committee. Money is available August 1, 2017.



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