The IAL - 2009 Batten Scholarship Application

IAL Website - 2009 Batten Scholarship
form submission

2009 Batten Scholarship Application

* A limited number of Batten Scholarships will be granted in 2009. 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 Batten 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 been a laryngectomee for a minimum of 2 years, have intelligible speech, and consider myself to be well-rehabilitated. I am primarily interested in providing peer support.
If you will be attending the Voice Institute from a country other than United States, please let us know your proficiency and comfort level with English. Please note that if you need an interpreter, their travel expenses are your responsibility. The IAL does not provide compensation for interpreters English is my primary language. English is not my primary language, but I speak, understand, read, and write English fluently. I will be using an interpreter.
Date of Laryngectomy: / MM / DD YYYY
Primary Method of Communication: Tracheoesophageal (TE) Standard Esophageal Speech Electrolarynx Other
My speech quality is: Excellent Good Fair Poor I am unable to Speak
My hearing is: Normal Fair Poor I wear a hearing aid
What would you like to gain from attending the Voice Institute?
Employment Status: Employed Unemployed Retired Disabled
Annual Income: Under $30,000 $30,000 - 40,000 $40,000 - 50,000 $50,000 +
Number of Dependents
Are you receiving additional financial assistance to attend the Voice Institute from any other source? Yes No
If yes, how much assistance are you expecting to receive?

I certify that I have never previously received a Batten Scholarship to attend the IAL Voice Institute. I further certify that it would be a financial hardship for me to attend the Voice Institute without financial assistance. I understand the maximum Batten Scholarship to be awarded will not exceed $500.00(US) plus the registration fee. I understand that the Batten Scholarship funds will be presented in the form of a check to the recipients of the award on the last day of the Voice Institute. I further understand that I must attend all designated classes in order to receive my Batten Scholarship.

Name First Last
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Phone - (###) - ### ####
Email

Although it is not mandatory, please feel free to submit any additional information in support of your application for financial support through the Batten Scholarship. Copies of such documentation are acceptable and should be appended to this application.

Please submit this form and any additional documents no later than May 15, 2009

Contact Information:
Jeff Searl, Ph. D., CCC-SLP, VI Director
The University of Kansas Medical Center
Hearing and Speech Department
3901 Rainbow Blvd. MS 3039
Kansas City, Kansas 66160
jsearl@kumc.edu

2009 Batten Scholarship Application

Contact Information: Jeff Searl, Ph. D., CCC-SLP, VI Director The University of Kansas Medical Center Hearing and Speech Department 3901 Rainbow Blvd. MS 3039 Kansas City, Kansas 66160 jsearl@kumc.edu

Contact Information:
Jeff Searl, Ph. D., CCC-SLP, VI Director
The University of Kansas Medical Center
Hearing and Speech Department
3901 Rainbow Blvd. MS 3039
Kansas City, Kansas 66160
jsearl@kumc.edu