Scholarship Form Apply now Step 1 of 2 50% Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth* Date Format: MM slash DD slash YYYY Birthplace*Number of years in Kansas*Father's NameOccupationMother's NameOccupationPlease list, if any, financial aid you have applied for or are receiving:Please list schools attended and degrees received.To which schools of optometry have you applied?Which schools have accepted you?Which school do you plan to attend? Save and Continue Later Explanation of Interest in Optometry (300 words or less)*Need for Scholarship (100 words or less)*High School Transcript*Accepted file types: doc, docx, pdf.College Transcript*Accepted file types: doc, docx, pdf.Optometry School Transcript*Accepted file types: doc, docx, pdf.Scholarship Interviews Optometrist*Accepted file types: doc, docx, pdf.Scholarship Interviews Educator*Accepted file types: doc, docx, pdf.Scholarship Interviews Applicants Choice*Accepted file types: doc, docx, pdf.Consent I do affirm that it is my intent to return to Kansas following graduation from optometry school in order to engage in the practice of optometry. I understand that in order fulfill the agreement under which the scholarship was given, I will practice on year in Kansas for each annual scholarship I receive. If I do not return to Kansas to practice optometry I understand I will be required to pay back to the Kansas Optometric Foundation the full amount of the scholarship.SignaturePhoneThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.