Leadership Scholarship Application

Leadership Scholarship Application

Elder Mother Cristeen Horton Leadership Award
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Date of birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Gender*

MaleFemaleOther
High School Name*
High School Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Current Grade Level*

FreshmanSophomoreJuniorSenior
Expected Graduation Date*

MonthDayYear
Date
Cumulative GPA*
Why are you applying for this scholarship?*
Essay (250-500 words)
What Leadership qualities have you exemplified during your high school tenure that reflect the legacy of Elder Cristeen Horton?*
Essay (250-500 words)

List your extracurricular activities, including sports, clubs, and organizations:

List your community service activities and volunteer work

	Organization	Position/Role	Duration
Activity 1
Activity 2

List any awards or honors you have received

	Name	Description	Date
Award 1
Award 2

Parent/Guardian Name*

First NameLast Name
Parent/Guardian Occupation*
Household Income*

Less than $20,000$20,000 - $50,000$50,000 - $100,000More than $100,000

Academic Reference*

	Name	Position	Contact Information
Reference

Academic Reference*

	Name	Position	Contact Information
Reference

Personal Reference*

	Name	Position	Contact Information
Reference

Applicant's Declaration

I hereby declare that the information provided in this application is true and accurate to the best of my knowledge. I understand that any false information may result in the disqualification of my application.
Applicant's Signature*

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Date signed*

MonthDayYear
Date
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