Scholarship Voucher

Scholarship Voucher Form for Colleges Participating in the Brother James Kearney Scholarship for the Blind

Student Information
All fields in this form are required unless otherwise noted.
Today's Date (required)*
MM slash DD slash YYYY
College Term (required)*
Please enter the college term for which Brother James Kearney Scholarship is requested:
Name of College or University (required)*
Student's Full Name (required)*
First Middle Last
Student's ID No. (required)*
Grade Level (required)*
Expected Date of Graduation - Year (required)*
Expected Date of Graduation - Month (required)*
Full-time Student (required)*
If not, please explain why the student is still eligible.
Student Eligibility Details (required)*
Student's State of Legal Residence (required)*
Student's Home Address (required)*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Student's Home Phone
Student's Mobile Phone
Student's Email
Scholarship Voucher
A | Total College Costs (required)*
(sum of four eligible costs – tuition, fees, room and board, books)
B | Total Non-Lavelle, Non-Loan Resources for College
Sum of #1, #2, #3
B.1 | Aid from State Commission for the Blind Funding or State Vocational Rehabilitation Agency (required)*
If none, enter 0, and then please explain in the details field below.
Aid from State Commission for the Blind Funding or State Vocational Rehabilitation Agency Details
B.2 | All Other Non-Lavelle, Non-Loan Aid (required)*
B.3 | Amount College Determines Family Can Pay Without Borrowing (required)*
C | Balance of College Costs
This field is automatically generated based on the data entered in the previous fields ( A minus total of B = C )
D | Amount Requested from Brother James Kearney Scholarship up to a maximum of $15,000 per year, $7,500 per semester or $5,000 per tri-semester. (required)*
Contact Person at College / University (required)*
First Last
Phone Number of Contact Person at College / University
Student’s Counselor at the State Commission for the Blind
First Last
Name
This field is for validation purposes and should be left unchanged.

Student Information

Scholarship Voucher