Test Form

Special Education Teacher Scholarship

If you are human, leave this field blank.

1. Demographic Data

First Name *

Last Name *

Date of Birth *

Email Address *

Street Address *

City *

State *

Zipcode *

Home Number *

Cell Number *

2. Personal Aspirations

Describe your future academic goal(s) *

Describe your career goal(s) *

Please write a paragraph about a person who made a significant difference in your life *

3. Schooling

Current High School *

Current School District *

Cumulative GPA *

Date of Gradutation *

I am a senior in high school *

Yes

I have applied to college *

Yes

I have been accepted to college *

Yes

4. Involvement

Involvement in Programs and Activities *

Please provide no more than five (5) programs and/or activities you have been involved in either inside or outside of your high school. Please list in descending order of significance. It is acceptable to leave lines blank in the event that there are no more activities to record.

Please Include "Name", "Description" and "Dates Participated" for each.

5. Awards

Awards and Recognition *

Please provide no more than five (5) awards or recognitions you have been given either inside or outside of your high school. Please list in descending order of significance. It is acceptable to leave lines blank in the event that there are no more awards or recognitions to record.

Please Include "Name", "Description" and "Provider" for each.

6. Teacher/Counselor

This section is for the individual who helped the special education student complete this application.

Name of Teacher/Counselor *

Contact Number *

Teacher/Counselor Email *

Todays Date *

Mailing Address:
ClaimAid
8141 Zionsville Rd
Indianapolis, IN 46268
Attn: IA Schools Scholarship