SAVANNAH STATE UNIVERSITY
PRISM SCHOLARSHIP PROGRAM
Application Form
Name:_______________________________________________________________________________
(First) (Middle) (Last)
SSN#: _________ - __________ - __________ Date of Birth: ____________________
E-mail Address:_____________________________ Savannah State Student ID 915__________
(if applicable)
Mailing Address (All correspondence will be sent to this address):
Street Address: _______________________________________________________________________
City: ___________________ State: ________________ Zip: _________
Home Phone: ( ) __________ - __________ Cell Phone: ( ) __________ -__________
Gender: Male Female
Race/Ethnicity:
African American Asian/Pacific American (please specify) _________________________
Latino/Hispanic (please specify) ______________
Native American/American Indian (please specify tribal affiliation) ________________________
White/Caucasian Other (please specify) _________________________________
Parent/Guardian: Name: _____________________ Phone: ( ) __________ -__________
Current Student Status:
If student is currently enrolled at a college/university:
Institution: ____________________________ City: _________________ State: _____ Zip: ______
Major: _______________Credit Hours Completed: ___ GPA: ____ (Include Transcript)
Expected Date of Graduation: ______
Did you receive a Hope Scholarship? Yes ______ No______
If student is graduating from high school:
School: ______________________________ City: _________________ State: _____ Zip: _______
Have you applied for admission to Savannah State University? Yes No
Have you been admitted to Savannah State University? Yes No
Extracurricular Activities:
List any extracurricular activities, awards, special recognition, achievements in sports/athletics, special interests, hobbies, etc.
_________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
References:
Three references whom you have asked to write recommendation letters: (Current college students should submit letters from science, math, technology, or engineering faculty members. Current high school students should submit letters from the high school principal, guidance counselor and science, math, technology or engineering teachers.)
Reference 1:
Name: ____________________________________ Institution: _________________________
Street Address: _______________________________________________________
City: ________________________ State: ________ Zip: _________
Phone: ( ) __________ - __________ Email: ____________________________
Reference 2:
Name: ____________________________________ Institution: _________________________
Street Address: __________________________________________________________
City: ________________________ State: ________ Zip: _________
Phone: ( ) __________ - __________ Email: ____________________________
Reference 3:
Name: ____________________________________ Institution: _________________________
Street Address: __________________________________________________________
City: ________________________ State: ________ Zip: _________
Phone: ( ) __________ - __________ Email: ____________________________
Personal Statement:
Your personal statement (at least 300 words typed/word-processed) should address all of the following topics:
The STEM (science, technology, engineering or math) major in which you are interested
Your career interests and reasons for your pursuit of that career
Reasons for your choice of Savannah State University’s PRISM Program (SSU-PRISM)
How your personal traits/skills/abilities will be of benefit to the SSU-PRISM Program and to your success as a PRISM scholar
How did you first find out about the PRISM Scholarship Program? (Please select one)
___High school administrator, faculty, or staff
___Savannah State University administrator, faculty or staff
___Savannah State University current or former PRISM Scholar
___PRISM Website
___Radio Announcement
___Letter mailed to you from the PRISM Program
___Other (specify)______________________________________________
I understand that if awarded a PRISM Scholarship, I must maintain a 3.0 GPA and participate in all activities (i.e., weekly mentoring, summer program activities, monthly seminars, presentations, mandatory meetings)
Signature of Applicant: ____________________________ Date: __________________
Checklist: ____I have signed my application
____I have included my completed application
____I have included my typed personal statement
____I have included three recommendation letters
____I have included my most recent transcript
____I have included my official SAT or ACT Scores (high school students)
Completed applications should be mailed to:
Dawn Howard
Program Coordinator
PRISM Scholarship Program
Savannah State University
P.O. Box 20089
3219 College Street
Savannah, GA 31404
Or deliver in person to Herty Hall, Room 100 (8:00am-2:00pm)
Students applying for fall 2012 consideration must submit all application material by April 30, 2012.
For more information, please email