Lori C. Pemberton Memorial Scholarship Application Form

Lori C. Pemberton Memorial Scholarship Application Form

Application Deadline - January 16, 2026
Read and follow the instructions carefully before submitting your application. You will need your most current official transcript and personal essay available for submission. All winners will be notified by the end of April 2026.
If selected, you will be asked for documentation to support the data you provide. Likewise, all correspondence and award agreements will be generated from the personal information submitted below. So, please use proper spelling, capitalization and punctuation.
I. Personal Data

Tell us about yourself
Full Name*

First NameLast Name
Birthdate*

MonthDayYear
Mobile No*
Email *
Where the confirmation will be send to
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Name*

First NameLast Name
Parent/Guardian's Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
High School*
Major Area of Study*
Please indicate what is your major are of study
Grade*
Current GPA*
Guidance Counselor/College Advisor*
Guidance Counselor/College Advisor Email*
example@example.com
Distinctions/Honors/Awards (academic/civic/government)*

0/300
How did you hear about the scholarship?*
Have you applied for other scholarships?*

YesNo
If yes, please list all scholarships?
II. Recommendations

Below, please provide the names, titles/positions of the two persons you have requested to submit personal recommendations on your behalf
Person 1
Name*

First NameLast Name
Position*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person 2
Name*

First NameLast Name
Position*
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
III. Volunteer Experience

List most current first
Title*
Date*

MonthDayYear
Date
Organization*
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duties*
Title (Additional volunteer experience)*
Date

MonthDayYear
Date
Organization
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Duties
Total years of volunteer experience:
VI. Co-curricular
List student clubs, organizations, and any extracurricular activities you are involved in.*
Additional comments:
VII. Autobiographical Statement

Personal Essay
The screening committee seeks to know what has influenced the development of your personality and values. You should address in your essay: social, historical, or political events that are of importance to you and how they have inspired you. Finally, conclude with your college goals and what you intend to achieve. Your essay should NOT exceed 500 words.
Essay*

0/500
VIII. Official Transcript
Official Transcript Upload*

Please submit your official transcript.
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IX. Applicant's E-Signature
By signing the space below, you are certifying that all information is correct and that you are the person completing this application. When you press the submit button, you will receive an email confirmation that your application was received. Please print for your records and retain as verification of your application.
Signature*

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Lori C. Pemberton Memorial Scholarship Application Form

I. Personal Data

II. Recommendations

III. Volunteer Experience

VI. Co-curricular

VII. Autobiographical Statement

VIII. Official Transcript

IX. Applicant's E-Signature