The David Mason Educational Fund Application Form

Personal Information

Name: *

Date of birth: *

Address: *

Phone number: *

Email address: *

Describe how you qualify to meet the main criterion of having a physical disability: *

Explain impact the physical disability has/had on your life, development and learning:

Education Insitutions Attended

Name:

Course:

Years attended:

Name:

Course:

Years attended:

Name:

Course:

Years attended:

Name:

Course:

Years attended:

Name:

Course:

Years attended:

Career Goal: What post-secondary education program/training are you pursuing or intending to pursue? Why?: *

* Canada Revenue Agency requirement.

What university/college/institute do you plan to attend?: *

List all organizations to which you have applied for funding and outline all monies received or pending toward your post-secondary education. Please include any scholarship monies that you anticipate or have confirmation of pending receipt.

Funding organization:

Confirmed:

Pending:

Funding organization:

Confirmed:

Pending:

Funding organization:

Confirmed:

Pending:

Amount requested:

(up to a maximum of $2,000)

Budget

Expense

% of requested grant

Tuition:

Books:

Houses/Living expenses:

Transportation:

Special Needs Assistance:

Ongoing therapy:

Other:

Total:

100%

The David Mason Educational Fund Application Form

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