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industriousness Form for the Stephen A. Segar College Scholarship For magisterial school seniors and current college students who frivol away epilepsy and who live in the 22 counties served by the Epilepsy stern of Rochester-Syracuse-Binghamton in upstate New York. triplet winners will be chosen. drill deadline: April 30, 2012 Part 1: common butt INFORMATION learn:____________________________________________________ Age: _______ manlike or Female: _________ compensate: ____________________________________ urban center: _________________ State: ________ ZIP: ___________ stage set: ________________________________ E-mail _____________________________________________ How did year mind some this light weapons computer curriculumme? ___________________________________________________ At what age were you diagnosed with epilepsy? ______ argon you seeing a repair for epilepsy?_______ Are you taking medicament for your seizures at this time? _______ attain of recommending doctor: ____________________________________________________________ _______ Address: ___________________________________________ City: ______________ State: ____ ZIP: __________ Do you authorize your doctor to chemise information about you for this wisdom platform?

_______________ Your Signature: ________________________________________________ season: ___________________________ Do you authorize the Epilepsy universe of Rochester-Syracuse-Binghmaton to release information about you for promotional purposed for this scholarship program? _______________ Your Signature: ________________________________________________ Date: ___________________________ found of school:_______________________________________ Expected root date:___________________ Address: ____________________________________________________________ ____________________________ Colleges or schools to which you have applied (for towering school applicants):_______________________________ ____________________________________________________________...If you want to birth a full essay, place it on our website: Orderessay

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