Bipolar Lives Scholarship Application

You are applying for the 2009 http://www.bipolar-lives.com scholarship. This is a cash scholarship of $500.00 USD, to be awarded on July 1, 2009. One scholarship will be awarded based on merit and at the sole discretion of the Bipolar Lives judging panel.
To be eligible you must be over 18 years of age on 06/01/09, be enrolled or enrolling in a US college, community college, technical college, or trade school, and complete both PART A and PART B of this application form in full, and submit your application by June 1, 2009. 

All applicants must submit an original submission as described in PART B, and certify their submission is their own creative work and has never been published or submitted elsewhere.

The award will be made to the person who most eloquently communicates important information about bipolar disorder, either based on the established research or drawn from personal experience. A variety of media may be used, as set forth in PART B.

PART A: Personal Details

NAME _________________________________________________
(Note: The scholarship check will be made payable to this name, in the event of a winning application.)

STREET ADDRESS: ________________________________________
________________________________________________________

CITY, STATE, ZIP: _________________________________________
(Note: This is the address the check will be mailed to, in the event of a winning application.)
NAME OF COLLEGE OR OTHER INSTITUTION: ____________________
________________________________________________________

MAJOR: __________________________________________________

GPA: ____________________________________________________

DATE OF BIRTH: ___________________________________________

Publication of winner’s details: The winner’s full name and address will NOT be published. However, initials and, state of residence and field of study will be published. For example, “E.H. of West Virginia, a nursing student.” Please check the box and type your name below to indicate consent to publication of your initials, state, and field of study:

I Agree 
Electronic signature (type full name): ____________________________  

PART B

Applicants must submit an original entry on one of the following topics. Please mark the topic of your entry. Multiple entries may be submitted but each entry must be unique and on a separate entry form.

Bipolar Stories ___			Bipolar Treatments ___		Bipolar Spouse ___

Bipolar Type II ___			Bipolar Symptoms ___		Bipolar Causes ___

Bipolar Treatment Centers ___	Claiming Disability ___		Bipolar Test ___

Bipolar vs ADHD ___			Bipolar Relationships ___		Lithium ___

Bipolar Chat Room ___		Bipolar Mood Charts ___		Bipolar Diet ___

Your entry must be either:
1. An original essay/article of 500 – 950 words, submitted as a Microsoft Word attachment, OR 
2. An original Microsoft PowerPoint presentation, with or without audio, OR
3. An original video in a format compatible with YouTube, length of 1 - 3 minutes, OR 
4. A Squidoo lens, published on www.squidoo.com, and containing a live link to any page on the www.bipolar-lives.com site.

Intellectual Property Assignment: Upon entry, your submission becomes the exclusive property of www.bipolar-lives.com and may be used to publicize this or future scholarships, or for other promotional purposes as the exclusive content of www.bipolar-lives.com. By checking the box and typing your name below, you assign all intellectual property rights to www.bipolar-lives.com, warranty you are the creator of the work, and indemnify www.bipolar-lives.com against any claims for damages or losses arising from intellectual property infringement. 

I Agree 
Electronic signature (type full name): _______________________________________  

Instructions: Email your completed entry form and original essay (as an MS Word attachment) or MS PowerPoint presentation, or YouTube compatible video, or URL for Squidoo lens (remember you only need to do one of the four) to sarah@bipolar-lives.com by midnight, June 1 2009. You MUST use "Scholarship Application" as the subject line of your email. Entries with other subject lines will not be opened. Winner will be notified July 1, 2009.
Bipolar Lives Scholarship Application                                                                                                   Page 2 of 2