VitAl Scholarship Application

VitAL Scholarship Application

Section 1: Personal Information

Full Name *

Date of Birth *

Age *

Gender

Contact Phone Number *

Email Address *

Home Address *

City *

State/Province *

Country *

Section 2: School Information

Current School Name *

Grade/Year Level *

School Address *

City *

State/Province *

Country *

Type of Enrollment *

Traditional School Homeschool (must meet applicable state homeschool laws) Accredited Post-Secondary Institution

Proof of Enrollment *

Section 3: Medical Information

Condition *

Vitiligo Albinism Both

Year Diagnosed *

Medical Certificate (optional at initial stage)

Section 4: Community Involvement & Advocacy

Describe your involvement in community activities (200–300 words) *

Required: 200–300 words.

Section 5: Personal Statement

Letter of Explanation (1–2 pages, double-spaced) *

Personal Essay (300–500 words) *

Personal Essay required: 300–500 words.

Section 6: Recommendations

Letter of Recommendation 1 *

Letter of Recommendation 2 *

Name and Relationship of Recommenders

Recommender 1 Name *

Recommender 1 Relationship *

Recommender 2 Name *

Recommender 2 Relationship *

Section 7: Consent & Agreement

I certify that the information provided is accurate and complete. * I certify that the information provided is accurate and complete.

I agree that scholarship funds will only be used for educational purposes. * I agree that scholarship funds will only be used for educational purposes.

I authorize Massé World to contact my school, references, or medical providers to verify information. * I authorize Massé World to contact my school, references, or medical providers to verify information.

Phone:	(877) 795 - 2194 (813) 945 - 2727
Fax:	(813) 945 - 2700
info@masseworld.org

VitAl Scholarship Application

VitAL Scholarship Application

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