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The Allegra Ford Thomas ScholarshipThe National Center for Learning Disabilities

www.NCLD.org [email protected] (888) 575-7373

2015-2016 Application

The National Center for Learning Disabilities is seeking applicants for the 2015-2016 Allegra Ford Thomas Scholarship. The Allegra Ford Thomas Scholarship is a $2,500 one-time scholarship awarded to a high school senior with a documented learning disability (LD) who will be enrolled, in the fall of 2016, at a two-year community college, a vocational or technical training program, or a specialized program for students with LD. The ideal Allegra Ford Thomas Scholar is a student who:

• Articulates his or her LD and recognizes the need for self-advocacy• Is committed to post-high school academic study/career training and has begun to set

realistic career goals• Has demonstrated perseverance and is committed to achieving personal goals despite

the challenges of LD• Participates in school and community activities• Demonstrates flnancial need

Eligibility & Selection Criteria

To be eligible for the 2015-2016 Allegra Ford Thomas Scholarship, an applicant must:• Be a senior in high school who will be attending a a two-year community college, a

vocational/technical training program, or specialized program for students with LD• Students who will be attending a four-year bachelor’s degree program, are not eligible

to apply for the Allegra Ford Thomas Scholarship. Please visit our website at www.NCLD.org for more information about applying for the Anne Ford Scholarship.

• Be a U.S. Citizen• Provide most current documentation of an identifled learning disability

Please Note: ADD/ADHD alone is not considered a learning disability; eligible candidates must also provide documentation of a specific learning disability.

• Demonstrate financial need

“I learn differently than everyone else but I do not

allow that to limit how much I am able to learn.”

- Macy Olivas, 2009 Anne Ford Scholar



Selection Process

The Allegra Ford Thomas Scholarship Committee, comprised of members of NCLD’s Board of Directors, Professional Advisory Board, and distinguished friends, will make the flnal selection of scholars in Spring 2016.

Scholarship Requirements

Allegra Ford Thomas Scholars are required to submit annual updates detailing their progress in their chosen fleld of study/work and offering insights about their personal and professional/academic growth. The $2,500 scholarship is paid in one installment. Scholars must provide proof of course/program registration to receive payment.

Submitting Your Application

Use the Application Requirements Checklist to make sure that all needed materials are included in the scholarship packet. All required materials must be received in one packet to be considered for the scholarship.

Complete packets only should be mailed to:

Complete application packets MUST be postmarked by December 15, 2015.

National Center for Learning Disabilities c/o Allegra Ford Thomas Scholarship32 Laight St., 2nd FloorNew York, NY 10013



Application Requirements Checklist

The Allegra Ford Thomas Scholarship is for graduating high school seniors who will be attending a two-year community college, vocational or technical college. If you are planning to attend a four-year bachelor’s degree program, please visit us at www.NCLD.org to apply for the Anne Ford Scholarship.

Use this checklist to keep track items needed for the Allegra Ford Thomas Scholarship application.

Please be sure you include the following materials in your packet:

Basic Information Form

Personal Achievement Form

Personal Statement Form

High school transcript (official or unofficial)

Three (3) letters of recommendation

Financial Statement Form

Most recent documentation of a learning disability

Submit all of these materials in one packet to:

National Center for Learning Disabilities c/o Allegra Ford Thomas Scholarship32 Laight St., 2nd FloorNew York, NY 10013



Basic Information Form – Page 1 of 3

APPLICANT INFORMATION (You may type in your answers and print the form. If you choose to handwrite, please write legibly.)

Applicant Name: Last First Middle

Date of Birth: Check One: Male Female Month / Day / Year

Mailing Address:

City: State: Zip Code:

Home Phone: Cell Phone:

Are you a US citizen?* Yes No

Email :

* Applicants must be current US citizens. If you have questions about your eligibility for this award, send your inquiry to [email protected]

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name(s):

Mailing Address (if different than above) :


Check all that apply: Parent Other relative (specify):

Legal Guardian Other (specify):

Home Phone (if different than above) : Cell Phone:

Email :

I would like to subscribe to NCLD newsletters, email updates and alerts. Yes No




SCHOOL HISTORY

High School(s):

Name of School City/State Years Attended

Middle School(s):


Primary/Elementary School(s):


How did you learn about the Allegra Ford Thomas Scholarship? Family School Website (please specify): Other (please explain):




LEARNING DISABILITY INFORMATIONPlease check which of these learning disabilities you have (check all that apply): Basic Reading (Dyslexia) Math Calculation (Dyscalculia) Reading Fluency (Dyslexia) Math Problem Solving (Dyscalculia) Spelling Executive Functioning/Organization Reading Comprehension (Dyslexia) Non-verbal LD Listening Comprehension (and processing) Other: Written Expression (Dysgraphia)

Date of initial diagnosis/classification:

Date of most recent testing:

OPTIONAL SELF-IDENTIFICATION African-American/Black (not of Hispanic origin) Asian or Pacific Islander (includes Indian subcontinent) American Indian or Alaskan Native Hispanic/Latino (Spanish culture or origin, regardless of race) White (persons of not Hispanic origin, having origin in any of the original peoples of Europe, North Africa or the Middle East) Race not included above (please specify): CERTIFICATION AND AUTHORIZATIONCertification: All of the information provided on this form is true and complete to the best of my knowledge. I certify that I have a documented learning disability, will be earning my high school diploma or its equivalent, and will be enrolling for the first time in a community college, vocational or technical training program, or specialized program for students with LD in the 2016-2017 academic year. I hereby authorize the National Center for Learning Disabilities (NCLD) to use excerpts from my essay along with non-financial information from my application for publicity and public relation purposes, provided that my confidentiality is protected. I understand that information contained in my essay may be used for research and/or publictiy related activities. All application materials including essays and transcripts become property of NCLD.

Authorization for Release of Information/Records: Applicants are responsible to arrange for transcripts and other required documentations to be submitted to NCLD. IN the event that NCLD finds it necessary to seek additional information, permission is hereby given to NCLD and its designees to contact school officials and others to request additional relevant information for use by the Allegra Ford Thomas Scholarship Selection Committee and/or NCLD staff.

Signature of Applicant: Date:

Signature of Parent/Guardian: Date: (required if applicant is under 18)



Personal Achievements and Activities Form – Page 1 of 3

Name: Last First Middle

PART 1: ACADEMIC INFORMATION Grades: You MUST sumbit a copy of your transcript.

Grade Point Average (GPA): Class Rank (if available): out of

Standardized Testing: As an option, you may submit either SAT or ACT scores (not required).

SAT Exam Date: / / Best Score: Math Critical Reading Writing

ACT Exam Date: / / Best Score: Composite

Are you planning to take either test again? Yes No If you have taken any other standardized tests (AP, IB, SAT Subject, etc.) and would like to share your scores, please do so below:




PART 1: EXTRACURRICULAR ACTIVITIESUse this section to list extracurricular activities (school clubs, sports, etc.) you have been involved in. If you need more room, attach a second page.

Activity Grades Involved Check all that apply

Hours per Week

Summer or School Year Check all that apply

Position Held, Awards/Honors, Other Achievements

9 11 10 12

Summer School Year Both

9 11 10 12


9 11 10 12


PART 2: COMMUNITY AND WORK EXPERIENCEUse this section to list any community, volunteer, or work experience you have. If you need more room, you may attach a second page.


Hours per Week



9 11 10 12


9 11 10 12


9 11 10 12





PART 3: OTHER ACTIVITIESUse this section to list any other activities you have been involved in. If you need more room, attach a separate page.


Hours per Week



9 11 10 12


9 11 10 12


9 11 10 12


PART 4: SPECIAL INTERESTS AND HONORS & AWARDSDo you have any additional special interests or hobbies? If so, explain below:

Since the 9th grade, have you received any special awards or honors? If so, list below:

Feel free to include any additional information or a resume as part of this application.



Personal Statement

Please pay special attention to this part of the application. Together with information provided in letters of recommendation, it is the best way for members of the review committee to get to know you and understand your journey as a student with LD.

In your Personal Statement, please address the following:

1. Tell us about your learning disability and how it has affected you in school, at home, and in the community.

2. Give us some examples of how you were able to overcome specific barriers to learning.

3. Tell us about the people in school, at home, or in the community who have helped you the most.

4. Describe any accommodations or assistive technologies that have helped you succeed.

5. What type of post-high school program are you planning to attend and what will you study?

6. How would the Allegra Ford Thomas Scholarship help you accomplish your goals?

“If President Obama wants to shore up this nation’s

pool of scientists and inventors, if Steve Jobs wants

ideas of how to unleash creativity, and superpower

countries want to move toward that next ‘big idea’,

there is an army of tens of thousands of LD students

like myself ready and willing to show how it is done.”

- Mackenzie Meyer, 2009 Anne Ford Scholar



Recommendation Form – Page 1 of 2

All applications must be postmarked by December 15, 2015. Please return this form and anyadditional documentation to the student so it can be included in the completed application packet.

Name of Applicant: Applicant Date of Birth: / /

The Allegra Ford Thomas Scholarship is a one-time $2,500 scholarship given to a high school senior with a learning disability (LD) who will be enrolled in a two-year community college, a vocational or technical training program, or a specialized program for students with LD in the fall.

The Ideal Allegra Ford Thomas Scholar is a student who will be attending a community college or career/technical program and:



the challenges of LD• Participates in school and community activities• Demonstrates financial need

INSTRUCTIONSStep 1: Please provide the following information about yourself

Name: Title:

School/Organization:


Mailing Address:

Telephone: ( ) - Ext.: Email:

How do you know the applicant?

How long have you known the applicant?




Step 2: Please complete the rating scale below

Below Average Average

Above Average

Well Above Average Outstanding

I Don’t Know

Academic Achievement

College or Career Readiness

Perseverance

Motivation

Self-advocacy

Understanding of LD

Leadership and Initiative

Involvement in school/ community actvities

Role model/spokesperson for people with LD

Use of accommodations and supports

Step 3: Please answer the following questions on a separate piece of paper.

1. Is this student an effective self-advocate? Explain.

2. How has this student reacted to setbacks or persevered in difficult situations? Please give examples if possible.

3. How well does this student understand his/her LD? Explain.

4. What are the three characteristics you most appreciate about this student?

5. Feel free to provide additional feedback about this student in your response.

Please return this form and completed additional pages to the student.












Name: Title:



Mailing Address:









Above Average


I Don’t Know



Perseverance

Motivation

Self-advocacy

Understanding of LD























Name: Title:



Mailing Address:









Above Average


I Don’t Know



Perseverance

Motivation

Self-advocacy

Understanding of LD














Financial Statement

To be filled out by the student’s legal parent/guardian. Completed application packet must be post-marked no later than December 15, 2015.


STATEMENT OF INCOME Please select an option belowOption 1: OR Option 2: Total income as reported on household’s Individual income reported by: (applicant and parent/guardian) most recent • Parent 1: $ federal income tax return: • Parent 2: $ $ • Student: $ (IRS Form 1040, Line 7) • Other: $ Total Number of exemptions claimed:

List all members of the household, ages and relationship to the applicant:

Is this a single parent family? Yes No Number of dependent children in family: Number of dependent children currently attending college: Planned year(s) of graduation: Number of dependent children currently attending high school: Planned year(s) of graduation:

COLLEGE/POST-SECONDARY PROGRAM INFORMATION

Those candidates chosen for final review by the Selection Committee will be asked to submit most recent copies of federal income tax returns and W-2 forms. Please attach any additional information that you would like to share regarding your financial situation.

Name Age Relationship Name Age Relationship

Name of college/program to which applicant applied Accepted? (Check one) Expected Tuition Costs

Yes Pending

Yes Pending

Yes Pending

Yes Pending

Yes Pending

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