Innovation Scholarship Application

Innovation Scholarship Application

Reverend Dr. Kenneth Haynes, Sr Innovation Award
Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
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 Innovative skills and accomplishments have you made during your high school tenure that reflect the legacy of Dr. Kenneth Haynes, Sr.*
Essay (250-500 words)

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

List your community service activities and volunteer work

List any awards or honors you have received

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*

Rows	Name	Position	Contact Information
Reference

Academic Reference*

Rows	Name	Position	Contact Information
Reference

Personal Reference*

Rows	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*
Date signed*

MonthDayYear
Date
Should be Empty: