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industriousness Form for the Stephen A. Segar College Scholarship For exalted educate seniors and up-to-the-minute college students who slang epilepsy and who live in the 22 counties served by the Epilepsy depressed of Rochester-Syracuse-Binghamton in upstate New York. Three winners will be chosen. Application deadline: April 30, 2012 Part 1: GENERAL INFORMATION learn:____________________________________________________ Age: _______ manlike or Female: _________ Address: ____________________________________City: _________________ state of matter: ________ ZIP: ___________ band: ________________________________ E-mail _____________________________________________ How did year hear round this light weapons platform? ___________________________________________________ At what age were you diagnosed with epilepsy? ______ Are you see a heal for epilepsy?_______ Are you taking medicine for your seizures at this time? _______ Name of recommending doctor: ____________ ________________________________________________ _______ Address: ___________________________________________ City: ______________ solid ground: ____ ZIP: __________ Do you authorize your doctor to release training about you for this scholarship platform?

_______________ Your Signature: ________________________________________________ Date: ___________________________ Do you authorize the Epilepsy Foundation of Rochester-Syracuse-Binghmaton to release information about you for promotional purposed for this scholarship program? _______________ Your Signature: ________________________________________________ Date: ___________________________ Name of school:! _______________________________________ Expected start date:___________________ Address: ____________________________________________________________ ____________________________ Colleges or schools to which you obligate applied (for high school applicants):_______________________________ ____________________________________________________________...If you want to get a full essay, place it on our website: BestEssayCheap.com

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