Application Information (Please print/ type all information)

Student Name ____________________________________________________________________________

Permanent Mailing Address _________________________________________________________________

College University access (email)_____________________________________________________________

Personal email ___________________________________________________________________________

Telephone Information: Home __________________________ Cell ______________________

Parent/Guardian __________________________________________________________________________

High School Information

Name of School __________________________________ Phone ________________ County____________

Address ________________________________________________________________________________

Name of School System _____________________________ Principal’s Name ________________________

College/Technical School Information

Name _________________________________________________________________________________

Address _______________________________________________________________________________

Approximate Enrollment Date ___________________________

Major/Program of Study (Education, Business, Cosmetology, etc.)________________________________

Student Certification, Authorization and Agreement

I certify that the information reported above and any other document or writing in connection with this application for the Helen R. Whitby Memorial Scholarship is or will be true, correct and complete to the best of my knowledge. I authorize the release and exchange of information to include technical school, college and university access for the purpose of being awarded this scholarship.

Student’s Signature _______________________________________________ Date ____________

Teacher/Counselor’s Signature ______________________________________ Date ____________

Parent/Guardian Signature__________________________________________ Date _____________

Pastor’s Signature _______________________________________________ Date _____________