IAGC Scholarship Application

Please attach a page to this application and fill in the necessary information.

Name:

Home Address:

City, State, Zip:

Home County:
(ex. Cook, Will, McHenry)

Phone: FAX:

E-mail:

On separate sheets of paper:

List past and current positions/responsibilities that brought you in contact with gifted children.
Please provide a brief statement describing how participation in the IAGC Convention would help you in your relationships with gifted children.

Please provide two references that we may contact regarding your scholarship request.

Name:

Phone:

Position:

Name:

Phone:

Position:

The enclosed information which I have provided as part of this application is accurate to the best of my knowledge.

__________________________________    _____________________
           Signature                          Date

Return form to:
IAGC Recognition Committee
Attn: Nancy Heaton
800 E. Northwest Hwy., Suite 610
Palatine IL 60074

Name:
Home Address:
City, State, Zip:
Home County: (ex. Cook, Will, McHenry)
Phone:	FAX:
E-mail: