/ Rockwall High School-Jacket Backer Athletic Booster Club
Student Scholarship Program
Application Form 2016-2017

Please complete the attached application and return it to the Athletic Office, no later than 4:00 pm, Friday, March 31, 2017. NO LATE APPLICATIONS WILL BE ACCEPTED. Please Print Legibly

APPLICATION DATE: ______

STUDENT NAME: ______

(as you wish for it to appear on your certificate)

ADDRESS: ______

(street address) (zip)

PHONE: ______email______

ROCKWALL HIGH SCHOOL VARSITY SPORTS: ______

(UIL Sports, Gymnastics, Powerlifting, Wrestling, Cheerleading, Stingerettes, Athletic Trainers)

CAMPUS ATHLETIC COORDINATOR/SECRETARY’S SIGNATURE:______

PART I: GPA (CUMULATIVE THROUGH THE 1ST SEMESTER SENIOR YEAR): ______

PART II: Pre-AP, AP, and Honors Classes taken during ENTIRE HIGH SCHOOL CAREER

1. ______8. ______

2. ______9. ______

3. ______10. ______

4. ______11. ______

5. ______12. ______

6. ______13. ______

7. ______14. ______

Form No. JB-004a / Complete page 2 of form
Page 2 / Rockwall High School-Jacket Backer Athletic Booster Club
Student Scholarship Program
Application Form 2016-2017
PART III: / Extra-curricular, Church and Community Service Activities
List all school organizations and church activities you were active in during high school only.
Organization/Activities / Role / Dates
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
List all community service activities you were active in during high school. Please include the name of the organization for which you volunteered, the number of hours that you have served and the contact information for the person who supervised your service. Please list each organization separately.
Organization/Activity / Contact / Dates
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
______ / ______ / ______
Form No. JB-004a / Complete page 3 of form
Page 3 / Rockwall High School-Jacket Backer Athletic Booster Club
Student Scholarship Program
Application Form 2016-2017
PART IV: / Word Essay: Put in writing your plans for the future and why you feel you are deserving of this award.
COUNSELOR’S VERIFICATION: / ______
STUDENT SIGNATURE: / ______
PARENT/LEGAL GUARDIAN SIGNATURE: / ______
Form No. JB-004a