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A scholarship program designed to assist students in our communities.

I. Applicant Data
Full Name*
First Middle Last
Age*
Date of Birth*

DD
MM
YYYY
Home Phone
Cell Number
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

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II. Parent or Guardian Information
Full Name*
First Middle Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Home Phone
Work Phone

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III. High School Information
(Transcripts are not required to be submitted.)
High School Name*
Phone Number
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
G.P.A.*
Graduation Date*
MM
DD
YYYY
Have you applied for Pell Grant or other financial aid?*
- Yes
- No
Guidance Counselor Name*
Phone Number*
(Transcripts are not required to be submitted)

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IV. Post Secondary School Data
Using official school name(s), name(s) of post-secondary school you plan to attend. (If unknown, list in order of preference the schools to which you have applied.)*
Name of post-secondary school City State

Click the "+" sign at the end of the row to add another school
If currently attending college, what is your G.P.A.?
Major or course study*
Anticipated date of graduation? (Month/Year)
Student will:*
- Live on campus
- Live off campus
- Commute from home
After graduating from post-secondary where do you plan to reside (city and state)?*

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V. Activities, Awards, Honors
List all school/community activities*
Activity # of Years Participated Special Awards/Honors Offices Held

List all school activities in which you have participated during the past four years (e.g. student government, music, sports, etc.) List all community activities in which you have participated in the past four years without pay (e.g. hospital volunteer, library volunteer, Boy/Girl Scouts, Special Olympics). Indicate all honors, all offices held and special awards.

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VII. Goals and Aspirations
Write a statement of your life in five years after earning your certificate or degree and how your childhood influenced your statement.*

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VIII. References
List three references with at least one being a teacher at your current school.*
Name Occupation Address Phone
Late applications will not be considered. If you have questions, please contact Jeralynne at 740.373.7406 x 3009

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Activity	# of Years Participated	Special Awards/Honors	Offices Held

Name of post-secondary school	City	State

Year	Employer	Brief description of duties

Name	Occupation	Address	Phone

I. Applicant Data