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 the program coordinator of your discipline, a faculty member, and a former high school teacher or counselor. Current high school students should submit letters from your high school principal or counselor and from 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
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)
____I have included my HOPE award letter (if applicable)
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)
For more information, please email