Application for the Youth Celebrating Courage and Freedom Scholarship
Please print or type. Return the completed form to your teacher by November 1, 2004.
Information is Related to the Student
Name of Student _____________________________________________
Address______________________________________________________
City ___________________________ State _________ Zip ________
Number of Persons in Household ________________________
# of Brothers _________ # of Sisters _________
_____Father _____Mother _____Both _____Other
$________________________________________________
AFDC/Welfare/Food Stamps/Foster Care Number ___________________________________
Amount Requested From the Scholarship Fund $ ____________________________
___American Indian ___Asian ___African American ___Hispanic ___White ___Other
Any Student Health Problems or Other Disabilities/Handicaps
_________________________________________________________
_________________________________________________________
Describe and Give Examples of Why the Student Needs Assistance
________________________________________________________________
________________________________________________________________
Describe and Give Examples of Positive Qualities or Abilities of the Student that are Related to the Scholarship Request
________________________________________________________________
________________________________________________________________
(Student) Write a 500 word essay regarding interests and future goals that are relative to the scholarship (use reverse side for completion):
_______________________________________________________________
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