Kentucky Council of the Blind
Educational Scholarship Application Form
Please complete and email this application, together with all requested documentation, to grants@kentucky-acb.org. This form must be computer generated and submitted by email. This application must be keyboarded on a computer. Handwritten applications will not be accepted. If you have questions after reading the KCB Scholarship Guidelines or if you need assistance completing this application, please email a description of your questions and needs and a telephone number where you can be reached to this email address.
The deadline for this application and all supporting materials is August 31 at 11:59 PM Eastern time; applications and supporting materials received after this date will not be considered.

PERSONAL INFORMATION (Please Type)
Applicant's Name:

Street Address:

City/State/Zip:

Summer Address, if Different from Above:
Street Address:

City/State/Zip:

Telephone:
Home:
Cell:

E-Mail:

Attendance at KCB State Convention
Are you able to participate in the Kentucky Council of the Blind Conference and Convention held during November 

Yes              No 

Participation in this convention either in person or on the Zoom platform is required in order to receive this scholarship.

Are you a member of KCB? 
Yes              No

If applicable, list the KCB chapters to which you belong:

Have you been awarded a KCB Educational Scholarship prior to this application?
If yes, please indicate year and amount received:

Year             Amount Received: $

EDUCATIONAL BACKGROUND
Name of School in which you are presently enrolled:

School Street Address:

School City/State/Zip:

Cumulative GPA (based on 4.0):

Major:

Note – you should be enrolled in a full course of study (minimum of 12 undergraduate or 9 graduate hours per semester).

Certificate:

Presently seeking Bachelor’s, Master’s, etc.:

Date degree expected:

If you are entering this school as a first-year student or transfer student, proof of acceptance must be included with your application materials. If you have not been notified of your acceptance, please indicate the date on which you expect to receive notice from the school.

List other secondary or post-secondary schools you attended:
1 Name of School:

School Street Address:

School City/State/Zip:

Dates Attended:

2 Name of School:

School Street Address:

School City/State/Zip:

Dates Attended:

3 Name of School:

School Street Address:

School City/State/Zip:

Dates Attended:

WORK EXPERIENCE
List all full- or part-time work experience. Include the employer's name, date(s) employed, duties, and whether this was summer employment or during the school year:

EXTRACURRICULAR ACTIVITIES
List all major outside activities (school, religious, community, sports, organizations of the blind, etc.) Include the extent to which you have played a leadership role.

Statement of Agreement

I have read the entire document titled "Kentucky Council of the Blind Educational Scholarship Program Guidelines," and I understand and agree to all terms and conditions contained therein. All information that I have listed on this application form is accurate to the best of my knowledge and correct to the best of my ability. I understand and agree that any failure on my part to wholly comply with the "Kentucky Council of the Blind Educational Scholarship Program Guidelines" or "Kentucky Council of the Blind Educational Scholarship Application Form" may void this application or otherwise render me ineligible for a KCB scholarship. By submitting this application, I hereby agree to receive information from the Kentucky Council of the Blind and its chapters, including but not limited to activities, events, programs etc., in the manner that KCB or its chapters deem appropriate. 

Signature of Applicant:

Date Submitted:

Email  this Application and supporting documents to:
grants@kentucky-acb.org 

Kentucky Council of the Blind
Educational Scholarship Program
148 Vernon Avenue
Louisville, KY 40206
Phone: (502) 895-4598
Email: grants@kentucky-acb.org