DANIEL A. BOUCHER

MEMORIAL SCHOLARSHIP FUND

P.O. Box 29, Uncasville, CT 06382

APPLICATION OF REQUIRED FACTS

STUDENT ATHLETIC SCHOLARSHIP AWARD

FOR HIGH SCHOOL SENIORS

GENERAL INSTRUCTIONS

Student’s Full Name:
Student’s Address:
(Street, City, State, Zip)
Date of Birth: / Place of Birth: / Phone:

Schools attended (ninth through twelfth grades):

Name of School / Date of Entrance / Period Attended
Name of School / Date of Entrance / Period Attended
Name of School / Date of Entrance / Period Attended
Date will graduate: / Number in Class: / Rank:
Father: / Occupation:
Name
Mother: / Occupation:
Name
Brothers/Sisters (ages):
Family members attending college:


ACADEMIC HONORS AND AWARDS (State year and nature of honor or award):

VARSITY ATHLETIC HONORS/AWARDS:

ACTIVITIES (School, Civic, & Work):

State your plans for enrollment in an accredited college or university:

DATE:
Signature of Student
DATE:
Signature of Parent/Guardian

Revision 03-1