Application Form

For your application to be considered, please complete the following questions in full. You are welcome to attach any supporting documents or provide further explanation for the Review Panel to consider (maximum of TWO (2) pages single-sided or ONE (1) page double-sided). Applications with missing information or supporting documents in excess of two pages will be disqualified.

All of the application questions are on this page so that you can see them at a glance.

Please review them in advance to ensure you have all the answers and materials ready, as you cannot save or return to this form at a later time once you begin.

To complete this application, you will need:

1. A cost estimate from your institution (1 page maximum)
2. A signed electronic letter of reference (1 page maximum)
3. Optional: Any additional supporting documents (2 pages maximum)

Please note: Applications that exceed the page maximum will automatically be disqualified.

Contact information

Personal experience with mental illness

Please answer the next questions as fully as possible, in as much detail as possible.

Education and Career

Financial need

Please fill out the expense form below and break down the expenses for your course of studies for one semester only. The categories of expenses covered by the Eleanor Pluchinski Scholarship include tuition, books, and other special course supplies that are payable to the campus directly. Books and other special course supplies acquired off-campus are not eligible expenses because award funds are issued directly to the educational institution.

References required

Please attach one letter of reference that is no longer than one page and is signed by the author. Please also complete the information below for this reference and one other. Both references must be a non- family member, such as an employer, therapist, doctor, social worker, teacher, community member, etc.

Reference No. 1

Reference No. 2