Social Security Number: ____________________________________________________

Name (last, first, middle): ____________________________________________________

Address: ____________________________________________________

____________________________________________________

Telephone: ____________________________________________________

Date of Birth: ____________________________________________________

High School: ____________________________________________ Years Attended: __________

Have you been notified that you will receive any other financial aid? _____________

If so, please detail: ____________________________________________________

____________________________________________________________________________________

Do you plan to work part time while attending college/vocational school? __________

II. Family & Worker Information

Foster Parent's or Guardian's Name: ___________________________________________________

Address (if different from above): ______________________________________________________

____________________________________________________________________________________

Case Worker: ___________________________________ Phone: _____________________________

III. Academic Record (to be completed by counselor or principal)

High School GPA: ____________________ Date of Graduation (or GED): _____________________

Course of study (college prep, vocational): _________________________________________

IV. Leadership Activities (please use extra sheet if needed)

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

V. Applying for (circle one) College, University, or Vocational School

Name: _______________________________________________________________________________

Address: ____________________________________________________________________________

______________________________________________________________________________________

Phone: _____________________________________

VI. Consideration for Scholarship - Requirements

a. Be a child in the state custody whether living in a foster home, group home, independent living placement, etc. Birth and/or adoptive children of foster parents are also eligible.

b. If chosen to receive scholarship, provide proof of acceptance into a college/university/trade or vocational school.

c. Fill out all the questions on this application.

d. Submit with this application three (3) letters of recommendation. Letters can be from foster parents, case workers, teachers, principals, guidance counselors, employers, pastors, etc.).

e. On a separate sheet of paper and in your own handwriting, make a brief statement of why you are applying for this scholarship. Include your hopes for the future and what you expect to contribute to society.

f. Be no older than 22 years of age.

VII. For Your Information

a. Unused portion or appropriate percentage of funds must be returned if recipient withdraws from school or does not maintain grade point average required by institution to reamin in school.

b. Scholarship funds may be used for tuition, maintenance fees, books, and/or school supplies.

c. Funds will be paid directly to the college/university or vocational school -- not to recipient.

All information contained in the above application is true and correct to the best of my knowledge.