Permobil Foundation Scholarship Form

Scholarship Application Form
“Every disabled person has the right to have his or her handicap compensated as far as possible by aids with the same technical standards as those we all use in our everyday lives”

-Permobil founder Dr. Per Uddén, 1967
As the philanthropic arm of Permobil, the Permobil Foundation is a non-profit organization that believes that regardless of disability, everyone deserves a chance to reach their dreams without limitations. No person should be excluded from opportunity due to a disability. Independent mobility is a basic human right. This is the heart of why Permobil cares.

Please read and follow the instructions carefully prior to submitting your application. If selected, you may be asked for documentation to support the data you provide.

Likewise, all correspondence and award agreements will be generated from the personal information submitted below. So, please use proper spelling, capitalization and punctuation.
Personal Data:

Tell us about yourself
Full Name *

First Name Last Name
Birthdate: *

Month Day Year
Mobile No. : *

Area Code Phone Number
E-mail : *
Where the confirmation will be send to
Home Address : *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
Education Data:

Tell us about your educational plan
Name of University or College *
Expected Date of Enrollment *

Month Day Year
Date
Major Area of Study: *
Please indicate what is your major are of study
Most recent cumulative GPA: *
What is your Career Objective: *

0/300
Extra-curricular activities, community activities, volunteer work, honors, offices held:
Do you have a contact or relationship with someone at Permobil? If yes, please share name and how you know them.
III. Agreements and Acceptance:
Certification and Acceptance: I certify that information contained herein is true and complete and accept the obligation to comply with the terms and conditions if request is awarded as a result of this application.

Non-Discrimination: The Permobil Foundation will not make contributions that discriminate on the basis of race, color, religion, gender, mental or physical disabilities, sexual orientation, national origin, age, citizenship, veteran/reserve/national guard status or other protected status; partisan political organization; or groups limited to members of a single religious organization

PUBLICITY WAIVER AND RELEASE AGREEMENT: I hereby irrevocably permit, authorize and license to Permobil Foundation and its licensees, assigns, successors, parent company, subsidiaries, owners, operators, and other affiliates, and each of the respective officers, directors, employees, shareholders, contractors, agents, associates, and representatives, (collectively “Assignees”), the universal, unrestricted and perpetual right to use my name, image, likeness, voice and/or appearance as such may be embodied or recorded in any photos, video recordings, audiotapes, digital images, or any similar medium, (collectively “Information”). I understand this waiver and release signifies that the Information described herein may be electronically displayed via the Internet or via any other medium with no time limit on or geographic limitation to which these materials may be distributed. By signing the in-kind product application and/or sponsorship application, I hereby waive any right that I may have to inspect and/or approve the finished works or the use(s) of the Information. I further hereby release, discharge and agree to hold harmless Assignees from any liability, any claim or cause of action, whether now known or unknown, for defamation, invasion of privacy, publicity or personality or any similar matter, or based upon relating to the use and exploitation of information.
IV. Applicant's E-Signature
By signing (typing your legal name) in the space below, you are certifying that all information is correct, you agree to publicity waiver and that you are the person completing this application.

When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.

If you have any questions please email us: info@permobilfoundation.org

Thank you for applying to the Permobil Foundation!
E-Signature: *
Should be Empty:

Scholarship Application Form

Personal Data:

Education Data:

III. Agreements and Acceptance:

IV. Applicant's E-Signature