Port Jervis Soapbox Derby Boo Bisland Scholarship

ELIZABETH ASHLEY "BOO" BISLAND MEMORIAL SCHOLARSHIP
Please complete all information on the form and obtain all required signatures, Return the form to the Port Jervis Soap Box Derby Scholarship Committee for their consideration. All information will be kept confidential.
Name*

FIRST NAMEMiddle NameLAST NAME
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
TELEPHONE*
Best Contact Phone Number
DATE OF BIRTH

MonthDayYear
Date
Sex at birth:

FemaleMale
High School Name*
INTENDED FIELD OF STUDY*
EMAIL ADDRESS*
example@example.com
APPLICANT'S SIGNATURE

Clear
DATE

MonthDayYear
Date
PARENT/GUARDIAN INFORMATION (If there is more than one parent/guardian, both should complete info requested below)
Parent/Guardian Name

First NameLast Name
RELATIONSHIP TO APPLICANT
EMAIL ADDRESS
example@example.com
LEVEL OF EDUCATION

APPLICANT PROFILE
CUMULATIVE GRADE POINT AVERAGE
Class Ranking
SAT SCORE
SCHOOL ACTIVITIES & CLUBS and Years Involved
List all School Activities and Clubs you are involved in.
LIST SCHOOL AWARDS, HONORS, AND SPECIAL RECOGNITIONS
Community Activities & Volunteering and Years Involved
IE: Youth Group food Pantry - 2 years
LIST COMMUNITY ACTIVITIES AND VOLUNTEERING AWARDS AND RECOGNITIONS
List special skills that you have obtained: (I.E. Playing the Piano, sign-language, second language, etc.)

WRITE A SHORT ESSAY (BETWEEN 150 - 500 WORDS)

AS TO WHY YOU THINK YOU DESERVE THIS SCHOLARSHIP AWARD AND WHY IS IT IMPORTANT TO BE INVOLVED IN YOUR COMMUNITY AND TO VOLUNTEER.

(attach essay to application below)
Essay Attachment

Cancelof

LIST CONTACTS FOR REFERENCES (BE SURE THAT ALL THE CONTACTS ARE ADULTS AND CAN BE REACHED BY TELEPHONE)
School Reference Name
School Reference Number
Neighbor Reference
Neighbor Reference Phone Number
Community or Activity Reference
Community or Activity Reference Phone Number

File Upload for any other documents

Cancelof
My signature below certifies that the information provided in this application is accurate and complete to the best of my knowledge. I authorize the Port Jervis Soap Box Derby Scholarship Committee to gather any information that it deems necessary from my school, activities, and programs to complete their evaluation of my application for consideration.
Print Name*
Signature*

Clear
Date

MonthDayYear
Date
Parent signature(s) are necessary if applicant is under 18 years of age.
Print Name
Parent Signature

Clear
Should be Empty: