HARRISON COUNTY STUDENT ACHIEVEMENT SCHOLARSHIP APPLICATION
Print out form and fill in information.
1. Name: ____________________________________________________________
Last
First
Middle
2. Home Address: ____________________________________________________
Street
City
____________________________________________________________________
Telephone #
E-Mail Address
3. _______________________________ M _____ F _____ ___________________
Social Security No.
Date of Birth
4. Father's or Guardian's name: __________________________________________
___________________________________________________________________
Occupation
Employer
5. Mother's or Guardian's name: ________________________________________
__________________________________________________________________
Occupation
Employer
6. Name of High School: ________________________________________________
Grade Point Average: ________________________________________________
Total ACT Scores: English __________ Math __________
Reading __________
Science Reasoning: _________________ Composite
Score: ________________
Dates tested: _______________________________________________________
SAT Scores: Verbal __________________________
Math __________________
Dates tested: _______________________________________________________
7. Please list any course work taken in the following areas during
high school:
Honors course work: _________________________________________________
___________________________________________________________________
Advanced Placement (AP) course work: _________________________________
___________________________________________________________________
College Classes: _____________________________________________________
____________________________________________________________________
8. List membership and participation in school organizations
and activities
including positions of leadership held,
if any. Please do not abbreviate club and
organizational names. (If extra space is
needed, please use another sheet and
attach.)
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
____________________________________________________________________
____________________________________________________________________
9. List membership and participation in community, civic and
religious
organizations and activities including
positions of leadership held, if any. Do not
abbreviate names. (If extra space is needed,
please use another sheet and attach. )
____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
10. List school or civil honors, awards or recognition. (If extra
space is
=needed, please use another sheet
and attach.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
11. College or Technical School Preferences:
Have you Have you
Intended
applied? been accepted?: Major?
1st. Preference: ______________________ ___________ ______________
__________
2nd. Preference: _____________________ ____________ ______________
_________
3rd. Preference: _____________________ ____________ ______________
__________
12. What do you want to do with your life that will not only make
you successful
but will also be beneficial to
your community? (If more space is needed , please
use another sheet and attach.)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
13. Work Experience:
Employer
Phone
Position
Employed
From To
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
14. Please describe in a brief paragraph why you feel you should
be the recipient of this scholarship. Include any unusual family
circumstances. (If more space is needed, please use another sheet and attach.)
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
15. Attachments:
(1) Two letters of recommendation
(2) Transcript
(3) Copies of ACT and
SAT Test Scores
16. Scholarship Preference--YOU MUIST SELECT THE CATEGORY FOR
WHICH
YOU WISH TO BE CONSIDERED:
( ) Academic
( ) Arts
( ) Technical
I certify that the information I have provided in this application
is complete and
accurate to the best of my knowledge.
_________________________________________
________________________
Signature of Applicant
Date |