Scholarship Application

Name

Physical Address

Mailing Address

City

State:
North CarolinaAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming

Home Phone Number

E-Mail Address

Date of Birth

Place of Birth

Gender
MALE FEMALE

FAMILY INFORMATION Parents/Guardian(s)

MOTHER

Mother's Full Name

Mother's Date of Birth

Mother's Address

Mother's Home Phone Number

Mother's E-Mail Address

Mother's Occupation

FATHER

Father's Full Name

Father's Date of Birth

Father's Address

Father's Home Phone Number

Father's E-Mail Address

Father's Occupation

EDUCATION: HIGH SCHOOL(S) ATTENDED

School / City / State / Dates of Attendance

ACTIVITIES and COMMUNITY INVOLVEMENT

ATHLETIC ACTIVITIES:

Please list all athletic activities in which you have participated during your high school career

Sports:

Letters won:

Special Sports Honors or Awards Received:

SCHOOL ACTIVITIES:

Please list all school activities in which you have participated during your high school career including clubs, student government, and other school organized activities.

Activities:

Positions of Leadership:

Special Honors or Awards Received:

Special Achievements:

COMMUNITY and RELIGIOUS INVOLVEMENT:

Please list any religious and community activities in which you have been involved during your high school career.

Activities:

Positions of Leadership:

Special Honors or Awards Received:

Special Achievements:

EMPLOYMENT:

Please list any employment you held during your high school career

Employer:

Position held:

Brief Job Description:

Dates of Employment:

SECOND JOB

Employer:

Position held:

Brief Job Description:

Dates of Employment:

ACADEMIC and PROFESSIONAL PURSUITS

What field of study do you plan to pursue?

Please list all colleges and/or universities you have applied to or plan to apply:

Name / City/ State / Status of Application

What career are you planning to pursue?

ESSAY PORTION

In a minimum of 1000 words, please discuss the following:

As there is a national growing trend to cut down on distractions while driving, a statewide task force has proposed a Bill in the Senate to reduce traffic injuries and fatalities by making inattentive driving a traffic infraction. The proposed Bill would first prohibit usage of all cell phones and other personal electronic communicating devices by the driver, or while the vehicle is being operated. Secondly the Bill proposes the following definitions be adopted as the basis for inattentive or distracted driving. Using/adjusting any personal electronic device, eating or drinking, interacting with children, pets, performing personal grooming or hygiene activities, reading or writing, all while operating a vehicle in an unsafe manner that results from engaging in a distracting activity. As a proponent or opponent of the proposed Bill, please indicate your opinion, and what changes, if any, you would like to see to the Bill.

HONOR PLEDGE

I completed this application on (date):

The Answers above are true to the best of my knowledge. The essay response is my own work.
TRUE

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