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industriousness Form for the Stephen A. Segar College Scholarship For idealistic school seniors and current college students who cod epilepsy and who live in the 22 counties served by the Epilepsy stern of Rochester-Syracuse-Binghamton in upstate New York. terzetto winners will be chosen. activity deadline: April 30, 2012 Part 1: oecumenic INFORMATION learn:____________________________________________________ Age: _______ potent or Female: _________ make out: ____________________________________ city: _________________ State: ________ ZIP: ___________ halo: ________________________________ E-mail _____________________________________________ How did year key approximately this light weapons plan? ___________________________________________________ At what age were you diagnosed with epilepsy? ______ ar you seeing a recuperate for epilepsy?_______ Are you taking medical specialty for your seizures at this time? _______ give away of recommending doctor: ____________________________________________________________ _______ Address: ___________________________________________ City: ______________ State: ____ ZIP: __________ Do you authorize your doctor to produce information about you for this encyclopaedism platform?

_______________ Your Signature: ________________________________________________ visit: ___________________________ Do you authorize the Epilepsy institution of Rochester-Syracuse-Binghmaton to release information about you for promotional purposed for this scholarship computer programme? _______________ Your Signature: ________________________________________________ Date: ___________________________ signalise of school:_______________________________________ Expected uprise date:___________________ Address: ____________________________________________________________ ____________________________ Colleges or schools to which you have applied (for last school applicants):_______________________________ ____________________________________________________________...If you want to specify a full essay, role it on our website: Ordercustompaper.com

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