Qualtrics Survey | Qualtrics Experience Management

Scholarship for Equipment or Services Related to a Physical Disability

Student's Name

Student's Penn ID

Student's Penn Email

Do you authorize Disability Services to determine your financial eligibility for scholarships? Only your name and type of scholarship for which you qualify will be shared with Student Registration and Financial Services. There will be no disclosure about your disability.

yes
No

Describe the equipment or services and the benefits they provide in relation to your physical disability.

How much does the equipment or services cost?

Are the cost of the equipment or services covered by health insurance, or any other funding source?

yes
no

If the cost is covered by health insurance or another funding source, identify the source and the amount covered.

Any additional information you might want to share regarding the need for the equipment or service.