Accident Survivor Scholarship Application

Item: Briskman Briskman & Greenberg
Author: Briskman Briskman Greenberg

Name*
First Last
Date of Birth*
MM slash DD slash YYYY
Email*
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Where are/will you be attending school?*
What is your current status at that school?
Using fewer than 500 words, tell us how you overcame a serious injury suffered as a result of a car accident, medical error, or other incident caused by someone’s carelessness.*
I understand that my name and photograph will be used to publicly announce the awarding of the Briskman Briskman & Greenberg Accident Survivor Scholarship if I am selected. I also understand that payment will be made directly to my school on my behalf.*

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The award will be paid directly to the winning applicants school on their behalf. Please consult with a tax professional regarding IRS reporting requirements, Topic 421 – Scholarships, Fellowship Grants and Other Grants.