Students applying for the Student Scholarship must:

1. complete Part I of the attached application and submit with the “Supplemental Data” requested in Part II of the application;

2. submit one “Faculty Evaluation of Student Application” form to a faculty member and request that it be completed and mailed to the co-chairs of the Mid-Eastern Symposium on Therapeutic Recreation. Faculty evaluation must be received by April 15th;

3. submit the application and supporting data no later than April 15th to:

Val Dickerson, CTRS
50 Pleasant Way,
Montclair, NJ 07042
Phone: (212) 539-6423
FAX: (212) 477-3121
Email: valstan50@yahoo.com

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STUDENT SCHOLARSHIP APPLICATION

Part I:

Name:

Mailing address:

Permanent Address:

Day phone:________________________ Evening phone:_________________

College/University:________________________________________________________

Department/Program:______________________________________________________

Number of credits enrolled in this semester:____________

List honors, awards and other skills and/or attributes:

Part II:

Submit the following supplemental data:

1. An official college transcript of the college/university you are presently attending

2. A current resume

3. Make certain that one “Faculty Evaluation of Student Application” form is mailed to the Scholarship Co-chairs no later than April 15th

4. The following statement signed and dated.

I understand that the Student Scholarship Committee cannot consider applications received after the deadline date, nor will they consider incomplete applications. I affirm that all the information contained in this application and supplemental data are true and accurate to my knowledge.

Signature:

Print Name:

Date:

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Detach Faculty Evaluation Form Below

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MID-EASTERN SYMPOSIUM ON THERAPEUTIC RECREATION
FACULTY EVALUATION OF STUDENT APPLICANT

To be completed by a faculty member in the student’s department and sent directly to the Chair of the Student Scholarship at:

Val Dickerson, CTRS
50 Pleasant Way,
Montclair, NJ 07042
Phone: (212) 539-6423
FAX: (212) 477-3121
Email: valstan50@yahoo.com

Applicant’s Name:________________________________________________________

College/University:________________________________________________________

Department/Program:______________________________________________________

As of the spring semester of the current academic year, this student is a:

[ ] graduate student or [ ] undergraduate student

Please write an evaluation of how the applicant would benefit from participating in the Mid-Eastern Symposium on Therapeutic Recreation and their potential to meaningfully interpret their experience to others.

How would you rank this student’s performance in comparison with other students at the same level of study? Please rank the applicant from 1 to 5, with 5 being the highest.

Rank:__________

This evaluation prepared by:

Signature:

Print Name:

Date:

Phone: