Application for Brain Injury Association of Missouri, Inc. Scholarship

Name of Applicant:_____________________________________    Date:  ______________

Address:______________________________________________________________________

_______________________________________________________________________

Phone:  _________________________                Age:_________              MO Resident:  Y     N

Date of Injury:  ________________          How Injury Occurred: __________________________

Name of Educational/Training Course:  _____________________________________________

Address of Educational/Training Course: ___________________________________________

                                                            ____________________________________________

Name of Contact Person at Educational Program:  ____________________________________

Phone number of Contact Person:  ________________________________

Name of Person Providing Reference:  ______________________________________________

Relationship to Applicant:  _____________________________

Please submit the following:

• 500 – 1000 word personal essay that includes:
• Statement about his/her brain injury and the affect it has had on his/her life,
• Description of goals,
• Explanation of how the scholarship will assist in achieving goals, and
• Description of current financial needs and other resources that will be used to meet the costs of the selected educational program. 
• Two letters of reference from an individual familiar with applicant’s abilities and educational/training goals, such as a teacher, rehabilitation therapist, counselor, or employer
• Verification that he/she is accepted to participate in educational/training program of choice

The Scholarship Committee will mail notices of award decisions within two weeks of the selection by the BIA Board.  All applicants, both selected and denied, will receive notification.