EmailMe Form - Michael Jon Barlin Scholarship Application

First Name *

Last Name *

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

County *

Email *

Cell Phone *

### - ### - ####

Home Phone

### - ### - ####

College/University *

Major *

I confirm (to be eligible you have to meet ALL of these requirements) that I: *

am currently enrolled and attending college as an undergraduate

am a primary resident of Florida

have been diagnosed with systemic lupus erythrmatous (SLE)

have a minimum cumulative GPA of 2.5

How did you hear about us?

Additional requirements

Upon completing of this application, the applicant must submit the following by May 31:

- an official transcript
- Physician's note stating that you have been diagnosed with lupus
- proof of primary residency in Florida
- one page statement of how lupus has affected his/her college experience

Please submit the supporting documents by May 31 via attachment or e-mail to: infose@lupus.org

Official Transcript

Physician's note stating that you have been diagnosed with lupus

Proof of primary residency in Florida

One page statement of how lupus has affected his/her college experience