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Dr. Gunnar B. Stickler Scholarship Purpose: The Stickler Involved People’s support group is proud to offer the Dr. Gunnar B. Stickler Scholarship Program. Dr. Stickler researched and discovered common genetic deficiencies in children and adults in the early 1960’s now known as Stickler Syndrome. His discoveries are proving important to today’s genome research. He desires to assist deserving college-bound adults afflicted with Stickler Syndrome to pursue their dreams and education goals. His understanding of the financial burdens for medical treatment (often required in raising a Stickler Syndrome child) and the need for higher education to help assure success as an adult, demonstrates his compassion for these children. The award is a Scholarship in the amount of $500 per year up to a maximum of 4 years. Eligibility: The scholarship application will be available to graduating students of any American high school who plan to apply for admission to any accredited public or private community, junior, or four-year college or university or vocational-technical school. Applicants must have a minimum grade point average (GPA) of 3.0 on a 4.0 scale or equivalent. You must be diagnosed with Stickler Syndrome by a primary care physician or Geneticist (on their letterhead), which must be attached to your application. Award: One new Scholarship will be awarded each year. The award is $500 per year until the Recipient graduated not to exceed 4 years. The Recipient must maintain a 3.0 or better GPA to continue to receive the annual award. Failure to meet this requirement for any semester will suspend your award until two consecutive semester’s GPA is 3.0 or better. Your college transcripts are due by July 1st to receive your next award installment. Scholarships are awarded on the basis of merit and financial need. Application: Interested students must fill out the application form completely and have all parties sign it. They must provide a Physician’s letter diagnosing their Stickler Syndrome. Students must enclose their high school transcripts (sealed). Applications are due by June 15th and will be reviewed by the Stickler Involved People’s selection committee by July 15th annually. The scholarship winner will be notified by mail by August 1st each year. Applicant’s final High School semester grades must be included with their transcripts. Mail applications to: Stickler Involved People Gunnar B. Stickler Scholarship Award C/O Pat Houchin 15 Angelina Drive Augusta, KS 67010 Gunnar B. Stickler Scholarship Application Application Deadline: June 15 Applicant Name: ________________________________________________ (Last, First, Initial) Permanent Address: ________________________________________________ ________________________________________________ (Street, City, State, ZIP) Permanent Phone Number:____(______)___________________ E-mail address:________________________ High School:_____________________________________ School Phone Number: __(_____)____________ School Address: ________________________________________________ ________________________________________________ (Street, City, State, ZIP) Sex: _____Male _____Female Date of Birth:____________________ Place of Birth:__________________ Are you a U.S. Citizen? ____ Yes ____ No Social Security Number: _______-______-________ Name of Institution Attending: ___________________________________ Address of Institution: ________________________________________________ ________________________________________________ (Street, City, State, ZIP) Anticipated Studies or Major:___________________________ Minor:_________________________________ Parents/Guardians Name: (Father)________________________ (Mother)_______________________________ Street Address: ________________________________________________ ________________________________________________ (Street, City, State, ZIP) Occupation: Father:__________________________ Employer:______________________________ Mother:_________________________ Employer:______________________________ Annual Household Income: ___Under $25,000 ___Under $50,000 ___Under $75,000 ___Under $100,000 ___Over $100,000 ___Disability Income Number of Siblings at Home:______ Number of Siblings in Post High School Institutions:_______ Activities, Awards and Honors Earned: _____________________________________________________________ _____________________________________________________________ I the undersigned, attest that all of the information provided herein is true and accurate and that any false representation may cause a disqualification and or revocation of this scholarship. ________________________________ ____________ (Applicant’s Signature and Date) ______________________________ ___________ (Parent/Guardian’s Signature and Date)