Nancy LaFevers Ambroze Scholarship Application Request

SCHOLARSHIP APPLICATION REQUIREMENTS

HBIDA has funds for scholarships to qualifying applicants for educational diagnostic testing.

Scholarships are:
• Funds donated by friends of the late Nancy LaFevers Ambroze and Jerry Ambroze.
• Scholarship amounts are coordinated by scholarship committee and diagnosticians.
• Funds are for educational testing for dyslexia, reading difficulties and learning disabilities.

---If approved testing will be covered directly by the HBIDA to preselected diagnostician---

Requirements to apply:

• Applicant must live in the Greater Houston area or in a regional group of The Houston Branch of IDA including College Station/Brian and the Golden Triangle areas.
• Applicants must be children/students between the ages of 3 – 17 years of age and adults between the ages 18 - 35 years of age. Exceptions can be made.
• Attached scholarship application must be completely filled out.
• Applications must have latest 1040 tax return attached with the ID number (SS) blacked out.
• Applicants must be tested by a qualified diagnostician who is a member of IDA.
• Identity of the scholarship recipient and testing results are confidential.

1. Today's date: This question requires a valid date format of MM/DD/YYYY.

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Upon receiving this request we will assign a scholarship committee member who will contact you within the next few week to discuss the application process.

2. Parent / Guardian first and last name:

3. Home address:

4. Contact information : At what phone number can we contact you?

5. What is the best date/time to contact you?

6. What is your email? This question requires a valid email address.

7. Applicant name (the person who needs the testing):

8. Age:

10. Current School:

11. Current School District:

12. Have you done any previous testing and or evaluations?

13. Give us a summary of the learning difficulty:

14. Please describe which testing and evaluations you have done, by home, and when?

14. Any identified dyslexia/reading difficulties in the family?

15. If awarded a current tax form must be provided.
Do you have an available tax form?

16. What is your current household income?

17. Please give us a little bit of background (few sentences) on why the scholarship is needed.
Or anything else you think we should know.

18. Who referred you to us (HBIDA)

Please enter an 'other' value for this selection.