Scholarships

Name *

First Name

Last Name

Cell Phone *

May be used as a form of communication

(###)

###

####

Address *

Applicant must be a resident of the United States.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Today's Date *

MM

DD

YYYY

Food Allergies *

Please check all that apply

Milk

Egg

Fish

Shellfish

Tree Nuts

Peanuts

Wheat or Celiac Disease

Soybeans

Sesame

Other

Eligibility Restrictions *

You are only eligible to receive the scholarships a maximum of two times within your academic years. Specifically, one time when applying as a graduating high school student and one time when applying as a current college/university/trade school student. There is no restriction for the amount of applications sent. Applicant must be a resident of the United States.

I understand

Consent *

I consent to Allergies Shaped My Life Foundation’s Privacy Statement and Website Terms and Conditions of Use, and further agree that in the event I am selected as a scholarship or basket recipient, Allergies Shaped My Life Foundation may publish my name as a recipient of such scholarship or basket on its website, in print or in any other form of media.

I consent