2012 Scholarship Application Program

American Council of the Blind

Dear applicant, thank you for applying to the American Council of the Blind Scholarship Program. Please take a few moments to review the critical application instructions that follow prior to proceeding to the online application. Doing so will ensure that you have organized yourself in such a manner that you have submitted all required documentation in a timely manner. Please copy and save this instruction page prior to proceeding so that you may reference them as needed.

Scholarship application instructions:

The American Council of the Blind scholarship application process must be completed online. Only approved supplements will be accepted by regular mail. See the mailing address below for submission of the supporting documents. Incomplete forms will not be processed and considered for review. Please do not leave any questions blank.

Include the following with your completed application:

1. Autobiographical sketch (details found in online application)

2. Certification of legal blindness from an ophthalmologist, optometrist or physician. (This hard copy letter may be mailed.)

3. Certified transcripts from the school you are currently attending. Entering freshmen, please include high school transcripts; graduate students, please include undergraduate transcripts. Unless extenuating circumstances exist, a 3.3 cumulative grade point average is required. (This hard copy letter may be mailed.)

4. Two letters of recommendation from a current or recent instructor, career counselor or employer. (Microsoft Word or Rich Text formats will only be accepted and can be emailed separately to: dmatthews@acb.org.)

5. Proof of acceptance from a post-secondary school. Entering and transferring students must submit a notice or letter from the admissions office certifying acceptance or consideration for admission. If not available at the time the application is submitted, it must be submitted as soon as it is available. Students continuing at the same school attended during 2011 do not need to submit this document. (Microsoft Word or Rich Text formats are preferred and can be emailed separately to dmatthews@acb.org.)

Completed application supplements (only) that are not able to be emailed must be postmarked no later than Thursday, March 1, 2012, to:

American Council of the Blind Scholarship Program,
Attn: Dionne Matthews
2200 Wilson Boulevard,
Suite 650,
Alexandria, VA 22201

Online applications must be submitted by 11:59 PM (EST) Thursday, March 1, 2012.

I. Personal Data: Name: (First, Middle, Last) *

Gender: *

Date of birth: *

E-mail: *

Mailing Address: C/O Street: *

City: *

State: *

Zip Code: *

Cell Telephone Number: *

Landline Telephone Number: *

Major field of study: *

Minor field of study: *

Cumulative Grade Point Average: (Based on a 4.0 scale) *

Class level for upcoming fall term: *

Vocational/Technical

Entering Freshman

Undergraduate

Graduate

Full Time or Part Time *

Full Time

Part Time

(Note: Full Time is considered 12 or more credit hours per term (semester or quarter) for undergraduates and 9 or more credit hours for graduate students.)

Are you working full time (32 or more hours per week) and attending school? *

Yes

II: Visual Status: When did you begin having problems with your vision? *

Please note: Legal blindness is defined as an individual who can not see better than 20/200 in the best eye with glasses or contact lenses or whose visual field in the best eye is 20 degrees or less at the widest diameter with glasses or contact lenses.

At what age did you become legally blind? *

What is the cause(s) of visual impairment? *

(Please include correct information on the cause(s)of vision loss, visual acuities and visual fields. Do not refer to the eye report that must be submitted.)

Visual Acuity: Right Eye *

Visual Acuity: Left Eye *

Visual Field: Right Eye *

Visual Field: Left Eye *

Can you see well enough to: Tell whether the light is on or off? *

Yes

Please describe the types of mobility aids you use to travel: (Check all that apply.) *

Cane

Dog guide

Sighted guide

Low vision aids (specify) *

Other devices (specify)

Please describe the types of adaptive communication tools that you use. (Check all that apply.) *

Other (specify)

III: Education Background: High school currently attending: Name:

A. (Question A is for entering freshmen Only.)

City and State:

Cumulative GPA (based on a 4.0 scale):

B. University/College or Vocational/Technical school currently attending: Name: *

City and State: *

Full time or Part time *

Full time

Part time

Cumulative GPA (based on a 4.0 scale): *

Date degree is expected: *

Major(s) and degree seeking: (BS, MA, etc): *

C. University/College you plan to attend in the fall of 2012, if different from question III B. 1st choice: Name:

Note: Proof of acceptance must be included with application materials. If you will not be notified by the time you submit this application, please indicate the date you expect to receive notice from the school(s).

City and State:

Major and degree:

Full time or part time

Full Time

Part time

Date degree expected:

2Nd Choice: Name:

City and State:

Major and degree:

Full time or Part time

Full time

Part time

Date degree expected:

D. Please list any other schools you have attended during the last four years if different from above. Name:

City and State:

Dates (mo/yr) attended: From:

Dates (mo/yr) attended: to:

Cumulative GPA (based on a 4.0 scale):

Major and degree or certificate received (if applicable):

IV: Test Record Information: ACT Date tested: *

Composite Score: *

SAT Date tested: *

Composite Score: *

SAT II Subject: Date tested: *

Composite Score: *

Other (GRE, GMAT, LSAT, etc.) specify *

Date tested: *

Composite Score: *

V. Work Experience: *

Please list any full-time or part-time work experiences that you have had in the last ten years. Indicate whether this was summer employment or during the school year.

VI. Extracurricular Activities: *

A. Please list your extracurricular activities (school, religious, community, sports, organizations of the blind, recreation, etc). Include the extent to which you have played a leadership role. A co-curricular transcript may be submitted and can be inserted into your application.

Will you be able to attend the ACB National Conference and Convention in Louisville, KY the week of July 7-14, 2012? *

Yes

ACB scholarship winners are expected to attend the ACB National Conference and Convention unless there are circumstances beyond their control and with the approval of the organization.

B. Have you received an American Council of the Blind Scholarship in the past? If so list what year(S). *

C. May we refer this application to another source of possible scholarship aid? *

Yes

Other, please specify

VIII: Autobiographical Sketch: *

A. Autobiographical sketch: No more than 500 words containing information about you. Tell us about your personal goals, strengths, weaknesses, hobbies, honors, achievements, etc. Be sure to list the field or courses of study you are pursuing and explain why you have chosen it.

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2012 Scholarship Application Program

American Council of the Blind

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2012 Scholarship Application Program

American Council of the Blind