FORM 1 – PERSONAL APPLICATION

Please type or print clearly and include ONLY the information that is requested in the spaces below.

To apply for this award, you must be able to respond affirmatively and check all of the following eligibility criteria:

I have a specific learning disability (please note that visual impairment alone does not indicate eligibility for this award). For the purposes of this award, a learning disability is defined as a neurological disorder that affects a person’s ability to receive, process, store, and/or respond to information, and which affects the person’s ability to read standard print

I have been registered as an RFB&D member for at least one year, up to and including the period of March 2, 2008 — March 2, 2009 (individually or through a school)

I am a member of the 2009 graduating class of a public or private school or home school in the United States or its territories, including U.S. military installations

I have an overall grade average of B (i.e. 3.0 out of 4.0) or above, based on grade levels
10 through 12 at the time of application

I plan to continue my formal education beyond high school at either a two- or four-year college or vocational school

First Name:

Last Name:

Home Address, Line 1:

Home Address, Line 2:

City

State Zip:

Telephone:

E-mail:

Date of Birth:

Anticipated Graduation Date:

Grade Point Average:

Describe your particular disability:

Are you registered with RFB&D individually? Yes No

If Yes, provide ID #

If you have a membership through an institution/school, provide details below:

Name/Membership # of institution/school:

Address, Line 1:

Address, Line 2:

City

State Zip:

Contact Name:

Telephone:

Duration of your membership?

Approximate number of RFB&D audiobooks read in the last 3 years (or, if membership is under 3 years, during your membership):

Name of school you are currently attending:

Name of school you will be attending next year (two- or four-year college or vocational study):

If you have not selected a college, please list the schools to which you have applied:

SIGNATURE

The applicant (or guardian) signature constitutes a pledge that this application is accurate to the best of their knowledge, that the application is entirely the work of the applicant and that the applicant meets all of the eligibility criteria. In addition, by signing this form, the applicant (and guardian, if under age 18) agrees to participate in RFB&D media activities and gives RFB&D the absolute right and permission to feature the name, photograph, videotape, quotes and/or information about the applicant in any RFB&D publication and/or public relations materials; and hereby waives the right to approve the finished product(s).

Signature:

Date:

Signature of parent or guardian:

Date:
(required if applicant is under 18 years of age)

Name of parent or guardian:

RFB&D USE ONLY:

Inst. Ind. Reg. Date: Exp. Date: