Paul Smith Scholarship Application

Please Submit by MAY 30th for consideration. (Extended to December 1st, 2022)

For high school seniors who have epilepsy and who live in areas served by the Epilepsy Foundation of Northern California. Recipient will receive $2,000 towards their college education.

First Name

Last Name

Phone

Address Line 1

Address Line 2

City

State

Postal Code

Age:

Telephone:

How did you hear about this scholarship program?

At what age were you diagnosed with epilepsy?

Are you currently taking medicine for your seizures?

Name of recommending doctor:

Address of recommending doctor:

Do you authorize your doctor to release information about your for this scholarship program?

YesNo

Do you authorize the Epilepsy Foundation of Northern California to release information about you for promotional purposes for this scholarship program?

YesNo

Name of High School:

Address of High School:

Please list the colleges to which you have applied:

Current grade point average:

List any honors or awards you have received in high school:

List any extracurricular activities you've been involved with outside of school:

Essay: Write a brief essay (500-700 words) related to living with epilepsy.

Required Documents: Please upload the following documents:

Signed letter of support from your physician:

Signed letter of support from your teacher or school advisor:

(Unofficial) copy of your school transcript:

A copy of your college application, acceptance letter, or confirmation of enrollment:

Photo of applicant (EFNC will use photo for promotional purposed related to this scholarship. Photo becomes property of the EFNC).

**High school seniors may not have an official acceptance notice from a college, vocational school, or trade school at this time. However, they should still apply for this scholarship and will be given full consideration in the process. Scholarship funds will be released contingent upon an official enrollment notice and tuition bill from the college or school.

Contact Information