Prefix

First Name

Middle Name

Last Name

Birthday (01/01/2019)

Phone Number [ex: (123) - 4567]

Email (ex: myname@example.com)

Street Address

Street Address Line 2

City

State

Postal / Zip Code

Country

Gender Gender Male Female

Are you a US citizen? Are you a US citizen? Yes No

Are you a Resident Alien? Are you a Resident Alien? Yes No

If not a US Citizen, tell us what country you are from

Currently employed? Currently employed? Yes No

If yes, please name your employer

Specialization (Please indicate what is your major area of study) Specialization (Please indicate what is your major area of study) Child Development Teacher Education Family member of Rett Health & Physical Educator Medicine/Pre-Medicine Music Education/Therapist Nursing Occupational Therapist Paraprofessional Parent of child with Rett Physical Therapist Secondary Teacher Education Speech Therapist OTHER

If other, please tell us your specification

Have you previously taken a Rett University course? Have you previously taken a Rett University course? Yes No

If yes, which one(s)

There is no right or wrong answer to the following questions. In order to get a grasp of your situation and how a Rett University scholarship will benefit the education of a student with Rett Syndrome, Rett University needs to have a clear vision of how you will use and apply our scholarship. Please tell us how Rett Syndrome currently plays a part in your home or work

Please tell us about your hardship. **Please upload documentation that proves financial hardship. Examples of this may include a copy of: W-2 form, pay stub, tax return, or unemployment letter. If you are international and reside outside of the United States, please upload any document/s that supports your current financial hardship.**

How do you hope to incorporate our Rett University Courses in your work with a student with Rett Syndrome and/or home life with a child with Rett Syndrome?

Applicant's E-signature Applicant's E-signature By signing (typing your legal name) in the space below, you are certifying that all information is correct and that you are the person completing this form.

E-Signature