STATE UNIVERSITY
SYSTEM OF
2009-2010
THEODORE
R. AND VIVIAN M.
JOHNSON
SCHOLARSHIP*
DEADLINE FOR APPLICATION
MATERIALS TO BE RECEIVED BY THE UNIVERSITY(IES): MAY 15, 2009
*This
program is contingent upon annual funding by the Theodore R. and
Vivian
M. Johnson Scholarship Foundation, Inc. and matching funding by the
The Johnson
Scholarship, funded by the Theodore R. and Vivian M. Johnson Scholarship
Foundation, Inc., is a competitively awarded program which is available to
undergraduate students with disabilities with financial need who enroll
in a State University System of Florida (SUS) institution. You must adhere to the following application
guidelines in order to qualify for full consideration.
In order to demonstrate
financial need, all applicants must complete a 2009-2010 Free Application for
Federal Student Aid (FAFSA) or Renewal FAFSA form, and mail it to the
appropriate address as indicated on the FAFSA form. To receive full consideration, the FAFSA should
be mailed or completed on-line no later than April 15, 2009.
INITIAL APPLICANTS MUST:
Provide an
official current transcript (not a photocopy) which documents a cumulative
grade point average of at least 2.0 (on a 4.0 scale) on all credits. High school students who are applying for the
first year of college should submit a current high school transcript.
Provide documentation of
the nature and/or extent of a disability.
The disability must be in one or more of the following
classifications: hearing impairment,
physical impairment; specific learning disability; speech/language impairment;
visual impairment; or other impairment.
Appropriate documentation includes, but is not limited to, either a
recent psychological evaluation used to determine eligibility for exceptional
student services, school/medical records, certification by the Division of
Blind Services, or a Vocational Rehabilitation eligibility determination. Documentation provided must meet the
guidelines require by the institution in which the student is enrolled. Students must contact the University Office
of Student Disability Services for clarification as to what is required.
Gain admission as a
degree-seeking undergraduate student into a State University System of Florida
(SUS) institution.
Have a demonstrated
financial need (determined from FAFSA information).
Be determined to be
Submit the following:
-
A completed 2009-2010 Johnson Scholarship
Application Form;
-
A current official transcript
-
Documentation of a disability(ies);
-
A personal statement (no more than one
double-spaced page) pertaining to your achievements, activities, career goals,
and the effects of your disability(ies); and
-
Three letters of reference (from a
non-relative) addressing your academic success and potential.
-
Mail or complete on-line a 2009-2010 FAFSA
form as indicated above.
RENEWAL APPLICANTS MUST:
Continue to
have financial need and adhere
to minimum enrollment, progress, and grade point average requirements of the
program, plus:
-
Submit a completed 2009-2010 Johnson
Scholarship Application Form to the desired SUS institution;
-
Mail or complete on-line a 2009-2010 FAFSA
form as indicated above.
Note: Former
out-of-state Scholarship recipients who are eligible may continue to seek
renewal.
APPLICATION PROCEDURES:
If you apply for
admission at more than one SUS institution, submit completed Johnson
Scholarship application materials to each university. The application should be sent to the contact
person listed at the end of this form.
Applications, disability
documentation, personal statements, letters of reference, and an official
transcript must be received by the
institution(s) no later than May 15, 2009.
All applicants
will be notified of their status as Johnson Scholarship recipients, alternate
award candidates, or as students who were not selected. Notification letters will be mailed in July
to the permanent address which is specified on the application forms.
IF SELECTED, RECIPIENTS
MUST:
Complete and return an
acceptance form by the date specified on your notification letter. Failure to return the acceptance form by the
specified date will result in forfeiture of the award.
First-time recipients
must participate in a Johnson Scholarship orientation.
Complete a minimum of
nine (9) credit hours each semester.
Adhere to the minimum 2.0
cumulative grade point average requirement of this program.
Apply for renewal
consideration for each academic year in which you desire the award. Johnson Scholarship recipients may qualify
for the award for up to twelve (12) semesters of undergraduate study.
After verification of
enrollment, the university will disburse the award on a prorated basis each
academic term to eligible Johnson Scholarship recipients. The dollar amount of the 2009-2010 awards is
contingent upon the level of funding from the Theodore R. and Vivian M. Johnson
Scholarship Foundation, Inc. and the Florida Legislature.
FOR ADDITIONAL
INFORMATION:
Call or write
the appropriate university representative listed on the last page.
Johnson Scholarship
funded by Theodore R. and Vivian M. Johnson
Scholarship Foundation, Inc.
2009
– 2010 Application Form
This form and supporting application
materials must be received by the appropriate
All
applicants must also
complete a 2009 – 2010 Free Application for Federal Student Aid (FAFSA) form or
Renewal FAFSA form on-line or mail it to the address indicated on the FAFSA
form by April 15, 2009 in order to
receive full consideration. PLEASE PRINT
OR TYPE.
_____Initial Application _____Renewal Application
NAME:_______________________________________________________________
Last First
Middle Initial
SOCIAL SECURITY
NUMBER:___________________________________________
CURRENT ADDRESS:___________________________________________________
Street Address
__________________________________Telephone:________
City
State Zip
CHECK ALL
DISABLING CONDITION(S) THAT APPLY:
_____Hearing
Impairment _____Speech
Impairment _____Visual Impairment
_____Physical
Impairment _____Specific Learning
Disability _____Other Impairment
CURRENT CUMULATIVE GPA:_____
UNIVERSITY:_____________________
HAVE YOU BEEN ADMITTED TO
THE UNIVERSITY? (check one) ___Yes ___No
2009 – 2010 ACADEMIC
LEVEL:
(check
one) _____Freshman _____Sophomore _____Junior _____Senior
ANTICIPATED UNIVERSITY
GRADUATION DATE:_______________________
SELECTIVE SERVICE
REGISTRATION
_____I am registered with
the Selective Service
_____I am not required to
be registered with the Selective Service because:
_____I am female.
_____I am in the armed services on
active duty (Note: This exception does
not apply to members of Reserve and National Guard units who are not on active
duty).
_____I have not reached my 18th
birthday.
_____I was born before 1960.
_____I am a citizen of the
permanent
resident of the Trust Territory of the Pacific Islands (
_____Other (please
specify):______________________________________
CITIZENSHIP STATUS (check
one):
_____I am a
_____I am a permanent
resident alien.
_____I am a non-U.S.
citizen or non-permanent resident alien and possess the following
category of
VISA (specify):______
ETHNIC ORIGIN (check
one*):
_____Alaskan Native _____Asian _____Black (non-Hispanic)
_____American Indian _____Hispanic _____White (non-Hispanic)
_____Pacific Islander
(*Failure to disclose
your ethnic origin will not disqualify your application)
Initial applicants must
submit to the appropriate University:
-
A completed 2009-2010 Johnson Scholarship
Application;
-
A current official (not a photocopy)
transcript;
-
Appropriate documentation of the nature
and/or extent of a disability;
-
A personal statement pertaining to your
achievements, activities, career goals; and
-
Two letters of references addressing your
academic success and potential. Letters
from relatives will not be accepted.
-
You must also mail or complete an on-line
FAFSA form to the address indicated on the FAFSA form by April 15, 2009.
Renewal
applicants must submit the following to the appropriate University:
-
A completed 2009-2010 Johnson Scholarship
Application.
-
You must also mail or complete an on-line
FAFSA form to the address indicated on the FAFSA form by April 15, 2009.
I certify that I
have read and understood the conditions for participation in this program. The information I am supplying in this
application is true, complete, and correct.
By signing the form, I also grant permission for information pertaining
to my financial need, and all supporting application materials, to be released
by the appropriate university to the Board of Governors Office for Academic and
Student Affairs. NOTICE: If you purposely give false information, you
may be subject to fine, or imprisonment, or both under 827.06, F.S.
_________________________________ _______________________
(Signature)
(Date)
SUBMIT
APPLICATION MATERIALS TO THE APPROPRIATE CONTACT PERSON(S) LISTED AT THE END OF
THE APPLICATION.
University Contacts
Submit
a completed 2009 – 2010 Johnson Scholarship application form and supporting
materials to the appropriate contact(s) listed below:
Ms.
Donna C. Shell
Asst.
Director, Learning Development
and
V: (850)
599-3180
TDD: (850) 561-2757
Ms. Nicole Rokos, Director
Office for Students with Disabilities
Post Office Box 3091
Voice: (561)
297-3880
TDD: (561)
297-0358
Ms. Cori Bright
Office of Adaptive Services
V: (239) 590-7956
TTY: (239) 590-7930
Ms. Amanda L. Niguidula, MPA
Interim Director
GC 190
TDD/V: (305)
348-3852
V: (305)
348-3532
Dr.
Bea Awoniyi
Assistant
Dean of Students
Director
of
V: (850) 644-9566; TDD: 850-644-8504
Christopher Pantzis, Director
Student Disability Services
New
Telephone: 941-487-4254
Email: Pantzis@ncf.edu
Dr. Pamela Rea, Director
Student Disability Services
V: (407)
823-2371
TDD Only:
(407) 823-2116
prea@mail.ucf.edu
Dr.
Jim Gorske, Assistant Dean of Students
Disability
Services Office
001 Building 0020 (Reid Hall)
Post Office Box 114085
V: (352)
392-8565
Dr. Kristine Webb, Director
TDD/V: (904)
620-2769
Raquel Peverini,
Diversity & Equal Opportunity
V: (813) 974-8616
TDD: (813)
974-5651
Associate
Dean of Students
Building
18/130
V: (850) 474-2161