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Office for Disability Services
The Pennsylvania State University
116 Boucke Building • University Park, PA 16802
Phone: 814 863-1807 (V/TTY) • Fax: 814 863-3217

Office for Disability Services Scholarship Application Form

Please print and return your completed application to the Office for Disability Services at the address listed above. If you have questions regarding scholarships, please call our number above or contact your Disability Specialist or Disability Contact Liaison.

Student Completes This Section
Please fill in the information and mail or fax to the Office for Disability Services.
Address and fax information is located at the top of this form

Student Name (Last, First, Middle):

PSU ID:

Age:

E-Mail Address:

Home Address:
Street :

City: State: Zip:

Home Phone number beginning with Area Code: -

Local Address:
Street :

City: State: Zip:

Local Phone number beginning with Area Code: -

1. Indicate your Penn State campus?
University Park
Other PSU campus (Name of campus):

2. Penn State Status:
Undergraduate (Semester standing?) (e.g., 2nd)

Graduate (Year of enrollment?) (e.g., 2nd)

3. List your Academic College (e.g., the College of Liberal Arts, the Smeal College of Business):

Major

4. Cumulative grade point average (This is your overall GPA):

5. Please check if you are attending (full time): or (part time):

6. Anticipated date of graduation (mm/yy):

7. Please place a checkmark beside the scholarship(s) you are applying for:

	Delta Chi Disabled Student Grant Fund		The Charles T. and Ella Fowler Douds Scholarship Fund
	Delta Gamma Golden Anchor Award		David R. Martino Memorial Scholarship
	Charlotte W. Newcombe Scholarship		Virginia G. Rimer Memorial Scholarship
	Bobbi Coulter Rich Scholarship		Jason C. and Martin Lee Stone Scholarship in Honor of Solveig and Frederick Samuel Dietz
	William Arthur Vogely Award Fund

8. What is your career plan following graduation from Penn State?

9. State your specific disability according to the Americans With Disabilities Act, 1990.

10. Explain below how the money will be utilized if awarded. Check as many of the items below that apply:
a) Expenses related to the disability, such as personal care attendants, readers or typists.
b) Defray costs during off-campus internships or work experience programs.
c) Partial tuition when all other forms of student aid have been exhausted.
d) Housing to enable me to live on campus or close to campus when this residence is due to the nature of the disability.
e) Assistive or adaptive equipment or technology (e.g., computer equipment, wheelchair, scooter canes, walkers, etc.)

Please explain any information checked above: Our donors ask for very specific information about how the recipients will utilize the money awarded. For example, include costs of medication, hourly wage paid to personal care attendant or tutor, miles driven to and from campus, tuition or books, etc. (If you require more space, please attach an additional sheet of paper to your application).

11. Check List: You must meet all of the criteria below in order for the application to be reviewed. Make certain all areas are complete prior to submitting your application.

a) You must have a cumulative Penn State University GPA of 2.0 or higher and must have been enrolled as a resident instruction student at any Penn State University location for at least two semesters to be eligible to apply for any ODS scholarship.

b) You have attached a copy of your current spring semester academic adjustment letter OR letter of verification from your Disability Specialist at University Park or the Disability Contact Liaison from the Penn State campus you attend.

c) You have filed a current FAFSA.

d) You have met the scholarship criteria outlined in the guidelines for each scholarship you are applying for.

e) You have completed the entire application, signed and submitted it to ODS by the April 30th deadline.

Applications will not be accepted prior to January 15th or after April 30th.

Signature:_____________________________________

Date:________________

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Web page last modified October 9, 2006