Skoski Scholarship Application Form

Christina Skoski, M.D., Scholarship Application

Personal Information

First Name*

Last Name*

Birthdate*

Contact Information

Email*

Mobile Phone*

Address Information

Street*

City*

State*

Zip*

Country

Additional Personal Information

What Type of Individual BEST Describes You? *

Additional Information

The next few questions are completely optional, and the answers won't determine your scholarship eligibility, but your answers would mean so much to us.

Would you be willing to answer a few questions to help us strengthen our efforts? Thank you for considering! *

Yes

Thank you for answering. If you prefer not to answer the optional questions, please skip to the Scholarship section to continue your application process.

Are you a:

Man

Woman

Prefer Not to Answer

Have You Ever Served in the United States Military?

Yes

Prefer Not to Answer

Occupation / School Status

Please Indicate Your Race

American Indian or Alaskan Native

Asian or Asian American

Black or African American

Native Hawaiian or Other Pacific Islander

White

Prefer not to Answer

Please Indicate Your Ethnicity

Assistive Technology Information

What is/are the Site(s) of Your Limb Loss and/or Limb Difference? (Select all that apply)

One arm/hand affected

Both arms/hands affected

One leg/foot affected

Both legs/feet affected

Both arms/hands affected

What was the Cause of Your Limb Loss or Limb Difference. (Select all that apply)

Related to diabetes or dyvascular complications

Related to trauma

Related to congenital limb absence

Related to cancer

Other

How Long have you Lived with Limb Loss or Limb Difference?

Do You use any Assistive Devices? (Select all that apply)

Cane

Crutches

Orthoses

Prostheses

Scooter

Walker

Wheelchair

Scholarship Information

Please enter the name of the postsecondary institution you plan to attend in fall semester.*

Will you be attending college full-time in the fall semester?

Please check the one that best describes your status in Fall:*

Freshman

Sophmore

Junior

Senior

Please List your extracurricular activities.*

Please enter your expected high school graduation date.*

Please enter your expected college graduation date.*

Student Certification

Choose All That Apply*

I give permission to my college and/or my high school to verify the information provided on this application with the Amputee Coalition.

I give permission to my college and/or my high school to release information regarding my college application, enrollment, and grade performance to the Amputee Coalition.

I certify that the information on this application is true and correct.

I agree to provide additional documentation if requested.

I understand that this form is used to establish eligibility for the Christina Skoski, M.D., Scholarship and that if I purposely give false or misleading information on this form, I may be subject to a fine, prison sentence or both, and such action may result in the forfeiture of awards from this program.

I understand that all awards are subject to the availability of funds.

I further certify that if I am chosen as a scholarship recipient, I will use the funds only for expenses related to my education in an institution of higher learning in the United States, and I will provide a transcript at the end of the school year for which the scholarship will apply.

Recommendation Letters

Brief Essay

High School GPA

Policy and Consent

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Student's Initials*

Application Date*