Thank you for your interest in applying to the Scott and Kim Verplank Foundation. We currently have twenty-two students receiving scholarships across the United States and this application is the first step toward being eligible for consideration for a scholarship.

The application, medical endorsement upload, reference names and phone numbers, and essay questions must be completed in full to be accepted. Once the application has been submitted, you will receive a confirmation with additional information.

General Information
First Name:
Middle Initial:
Last Name:
DOB:
Address:
City:
State:
Zip:
Home Phone:
Mobile Phone:
Email Address:
Mother Name:
Mother Mobile Phone:
Mother Email:
Father Name:
Father Mobile Phone:
Father Email:
Siblings and Ages:
Medical History
When were you diagnosed with diabetes?
:
Medical Endorsement:
Please have a doctor or other qualified medical professional provide a letter to confirm your diagnosis and care. (.doc .docx .pdf)
Education
High School:
High School City:
High School State:
Expected Graduation Date:
Current GPA:
Education Awards/Honors:
  Please provide name of counselor or teacher with contact information who can serve as a reference for your academic achievements.
Counselor Name:
Counselor Title:
Counselor Phone Number:
Counselor Email:
Athletics
Sports:
  Please provide name of a coach with contact information who can serve as a reference for your athletic participation and achievements.
Coach Name:
Coach Title:
Coach Phone Number:
Coach Email:
Extracurricular Activities
Extracurricular Activities Clubs and Awards and Years:
Service and Philanthropic Involvement and Awards and Years:
ESSAY
  What is your most meaningful achievement to date and how does it relate to your future goals? Please limit your response to 250 words.
Most Meaningful Achievement:
Signatures
I testify that the statements written in this application are truthful and complete to the best of my knowledge.
Student Signature:
Parent Signature:





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