Please have your physician of record, or your Vocational Rehabilitation Counselor complete the following information and submit with your scholarship application.

Name of Patient/Client________________________________

Address ___________________________________________

City _____________________________St_____Zip________

Date of Birth ____________ Onset of Disability ___________

Diagnosis __________________________________________

Prognosis __________________________________________

__________________________________________________

Recommendations __________________________________

Name of Physician/Counselor _________________________

Address __________________________________________

City _____________________________St_____Zip________

Phone __________ Fax____________Email _____________

Print Name _________________________________________

Signature _______________________Date ______________