2005 BATTEN SCHOLARSHIP APPLICATION

* A limited number of Scholarships will be granted.  The information provided on this form will be used to determine which applicants would most benefit from financial assistance.  Individuals who submit incomplete forms will not be considered for a Scholarship. 

I would like to apply for a Scholarship to attend the Voice Institute as a:

_____ Voice Institute Pupil (VIP).  I am primarily interested in improving my own 

            communication.

_____ Laryngectomee Trainee (LT).  I consider myself to be well rehabilitated.  I have

           intelligible speech and have been a  laryngectomee for a minimum of 2 years.  I am

           primarily interested in helping other laryngectomees improve their communication skills.

Date of Laryngectomy:

Primary Method of Communication:  TEP    Standard   Esophageal Speech          

                                                                Electronic  Larynges     Other_________

My speech quality is: Excellent   Good   Fair   Poor   I am unable to speak

My hearing is:  Normal   Good with hearing aids   Fair    Poor  

What would you like to gain from attending the Voice Institute? ____________________________________________________________________________________________________________________________________________________________

Employment Status:  Employed     Unemployed       Retired      Disabled    

Annual Income: under $ 20,000   $30,000-40,000   $40,000-50,000 60,000+   

Number of Dependents:

Are you receiving additional financial assistance to attend the Voice Institute from any other source?  No/Yes.  If yes, how much assistance are you expecting to receive? $________

I certify I have never received a scholarship to attend the Voice Institute and it would be a financial hardship for me to attend the Voice Institute without financial assistance. I understand the Scholarship amount is up to $ 500.00 plus the registration fee.  I understand Scholarship funds will be presented in the form of a check to the recipients on the last day of the Voice Institute. I further understand that I must attend all designated classes in order to receive my scholarship funds.

Signature: ______________________________________

Name (print):____________________________________

Address: _______________________________________

City, State, Zip:  _________________________________

Phone Number:__________________________________

E-mail address: __________________________________

Although it is not necessary, please feel free to submit any additional information in support of your financial need, in the form of an attachment.

Return this form by June15, 2005 to:

Caryn F. Melvin PhD.

Dorn VA Medical Center

Speech Pathology (126)

6439 Garners Ferry Rd.

Columbia, SC 29209

Caryn.Melvin@med.va.gov

803 776 4000 ext 6458

Fax 803 695 7908