Maryellenlocher Foundation 2018-19 Scholarship Application Form

MaryEllenLocher Foundation 2018-19 Scholarship Application Form

Thank you for your interest in our scholarship program. Please be sure you have included all required documents for consideration. These are found on our website under “Application Checklist.’’ IF ALL DOCUMENTS ARE NOT INCLUDED WE CANNOT CONSIDER YOU FOR A SCHOLARSHIP. YOUR PERMANENT ADDRESS MUST BE WITHIN A 50-MILE RADIUS OF CHATTANOOGA, TENNESSEE TO BE ELIGIBLE.

NOTE: Please list honors, activities, offices held, volunteer/church work, etc. on a separate sheet of paper and attach to this application.

Student Information

Applicant’s full name ______

Street address______

City, state, zip code ______

Phone number ______Cell phone number ______

Most used e-mail address______

Social Security number ______Date of birth______

Gender ______U.S. citizen? ______

Parent or Guardian Information

Parent or guardian name ______

Street address ______

City, state, zip code ______

Phone number ______Parent cell number ______

Parent e-mail address: ______

Sibling Information

Names and ages ______

Personal Reference Information

Personal reference’s name ______

Street address ______

City, state, zip code ______

Phone number ______Relationship to applicant ______

Student Education Information

High school or college currently attending ______

Address ______

Phone ______Graduation date ______

If currently in college, what high school did you attend? ______

How did you hear about this scholarship? (school contact, physician, Internet research, friend or family member, etc). ______

Future Academic Plans

College/university you plan to attend ______

Intended major ______Anticipated graduation date ______

Are you applying for the “Tennessee Promise’’ program? YES ______NO ______

Student and Parent/Guardian Affirmation

By applying for this scholarship, students agree to give the MaryEllenLocher Foundation permission to use the applicant’s name, photographs of self and family, and essay information on all promotional material, the foundation’s Facebook page, and the official foundation website,

Both the student and the parent/guardian must read the following statement and sign as indicated.

We affirm that the information provided on this application is accurate to the best of our knowledge. We understand misrepresentations may constitute fraud which may result in loss of eligibility of this scholarship or have other legal consequences. We give permission for the Selection Committee of the MaryEllenLocher Foundation Scholarship Fund to review student transcripts and other personal information.

______

Applicant SignaturePrint NameDate

______

Parent SignaturePrint NameDate

Awareness Project Agreement:

I, ______, understand that completion of a breast cancer awareness activity is REQUIRED of all recipients of scholarships from the MaryEllenLocher Foundation Scholarship Fund. I understand that an explanation and details of my participation must be given in my renewal application for the next academic year.

Applicant’s signature ______Date ______