Connecticut Roller Derby Cindy Luberto Scholarship for Women Identifying/Non Binary Athletes - 2020 - Application Form
Applicants must:
-be a woman identifying/non binary student athlete, participating in recreational, community, or school athletics
-be attending a Connecticut college or university in the Fall of 2020, or be a Connecticut resident attending any college or
university in the Fall of 2020
-provide a 250-word essay describing their passion for the sport that they play, with emphasis on how their sport or their
participation is unique
-provide a photograph of themselves in action or representing their sport
-agree to allow Connecticut Roller Derby, Inc., to use submitted information and photograph in promotional materials
complete and submit the application and recommendation by April 1st, 2020

*Past or current members of CTRD or the immediate family of any current CTRD member are ineligible.
Deadline/How to submit:
* Submit all materials by April 1st, 2020. Application online is at, but also may be submitted by email to or by mail to CT Roller Derby Scholarship, PO Box 1774, Naugatuck, CT 06770.
Email address *
Full Name *
Your answer
Date of Birth *
Your answer
High School Attended *
Your answer
Date of Graduation *
Your answer
College attending (or planning if not yet accepted/ decided) *
Your answer
Do you anticipate receiving an athletic scholarship to participate in sports while at college? *
I agree to allow Connecticut Roller Derby, Inc. to use my submission in promotional materials, including home town, schools attended, content of essay, and photograph. My private information, such as home address, phone number, and email address, will remain private and are only submitted for contact purposes. *
I understand my personal information will be protected and will not be given or sold to any third parties. *
The information in this application is true and accurate to the best of my knowledge. *
250 Word Essay describing your passion for the sport(s) you play with emphasis on how your sport or participation is unique. *
Your answer
A copy of your responses will be emailed to the address you provided.
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