Latreese Nicole Fagan Memorial Scholarship Fund, Inc.
2004-2005 Application

Please print this page containing the

Latreese Nicole Fagan Scholarship Memorial Fund Application Form

Complete the requested information and send it to the address below. Please enclose additional pages with this application. 

A person may nominate someone for this scholarship.  The application process can be initiated by the person who has lupus or a non-relative nominating a person with lupus.

You may also request an Application Form by writing, e-mailing or calling:

Lupus Alliance of Michigan / Indiana
Attn: Thomas G. Roberts – CEO
26507 Harper Avenue
St. Clair Shores, Michigan 48081

(800)705-6677 ~ Fax (586)775-8310
info@milupus.org info@latreesefagan.org


FOR 2004-2005 ACADEMIC YEAR COMPETITION:

  • Available funds of $1,000 for individual awards.

  • Money is to be used to cover tuition, books, fees, room and board. 

  • Funds will be made payable to the accredited institution of higher learning.

LNFMSF - Accepting Scholarship Application:
Start Date: October 1, 2004
End Date:  March 31, 2005
 
Latreese Nicole Fagan
Memorial Scholarship Fund, Inc.

Application Form (2004-2005)

 

Applicant Information
     
Last Name:
First Name: M. I.:
 
Street  Address: Apt:  
City: State:   Zip:  
 
Phone: (Day) ()-- Martial Status: Single Married
Phone: (Eve.) ()--
Fax:: ()-- U.S. Citizen: Yes No
 
Date of Birth: // Social Security
Number:		 --
 
Email Address:
Parent( ), Guardian( ), or Spouse( )
   
Last Name:
First Name: M.I.:
 
Street Address: Apt:
City: State: Zip:
 
Phone (Day): ()--
Phone (Eve.): ()--
Fax: ()--
Page 2

   To Be Completed By Primary Care Physician:
   
Physician's Last Name:
Physician's First Name:
Office Address: Suite:
City: State: Zip:
Office Phone: ()--
Office Fax: ()--
Diagnosis: Please attached additional sheets if space provided below is insufficient.
Signature:
Date: //
Page 3
High School Information:
High School Name:
Street Address: Apt:
City: State: Zip:
Telephone: ()--
Date of Graduation: //

   
  Higher Learning Institution
Planning to Attend or Presently Attending:
Institution Name
Street Address Apt:
City State: Zip:
Phone ()--
Expected Date of Graduation //
Undergraduate Year:  
Beginning Year:
Planned Completion:
Degree(s) Pursued:
Subject/Major(s):
Vocation Pursued:
 
Page 4
 

Nomination and References:

If a person is nominated by a non-relative, only two(2) letters of recommendation are required.  If a person with lupus applies directly, three letters of recommendation are required.   Recommendation letters can be from a physician, pastor, counselor, teacher, principal, employer, or non-family member attesting to the applicant’s character, personality, and academic ability.
 
Reference #1
  Last Name:   Relationship:  
First Name: M.I.:
Street  Address: Apt
City: State Zip
Phone ()--
 
Reference #2
  Last Name:   Relationship:  
First Name: M.I.:
Street  Address: Apt
City: State Zip
Phone: ()--
 
Reference #3
  Last Name:   Relationship:  
First Name: M.I.:
Street  Address: Apt
City: State Zip
Phone: ()--
Page 5
 
Awards, honors, community, campus, church,
or other outside activities.
   
Please attach additional sheet(s) if the space provide below is not sufficient.
Awards:
Honors:
Community:
Campus:
Church:
Outside Activities:
Page 6
 

Essay
Provide an essay on the topic "My reasons for desiring a higher education."

The three(3) letters of recommendation (or two(2) letters of recommendation and one (1) nomination letter) and the essay that a candidate submits to the committee will play an important role in the selection of the winning candidates.  It is therefore in each candidate’s best interest to obtain letters that most adequately describe their characters, personalities and abilities and write a detailed essay.
I have answered the questions to the best of my knowledge.
Signature:
Date:  //
Page 7