SCHOLARSHIP APPLICATION
STUDENT INFORMATION
NAME
*
SALUTATION
FIRST NAME
M.I.
LAST NAME
ADDRESS
*
STREET ADDRESS
STREET ADDRESS LINE 2
CITY
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
STATE
ZIP
EMAIL
*
example@example.com
CELL PHONE
*
Please enter a valid phone number.
Format: (000) 000-0000.
GENDER
*
Please Select
Male
Female
Not declared
PARENT OR GUARDIAN
*
First Name
Last Name
RELATIONSHIP TO STUDENT
*
CELL PHONE
Please enter a valid phone number.
Format: (000) 000-0000.
HIGH SCHOOL INFORMATION
HIGH SCHOOL
*
DISTRICT
*
Please Select
Chesterfield
Hanover
Henrico
City of Richmond
Home Schooled
Private
GRADUATION YEAR
*
OVERALL GPA
*
COUNSELOR
*
COLLEGE INFORMATION
COLLEGE PLANNING TO ATTEND
*
INTENDED MAJOR
IF KNOWN
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STUDENT EMPLOYMENT
Rows
TYPE OF WORK
APPROXIMATE DATES
HOURS PER WEEK
NUMBER OF MONTHS
1
2
3
4
COMMUNITY SERVICE AND VOLUNTEER WORK
Rows
NAME OF ORGANIZATION
9
10
11
12
YOUR ROLE
1
2
3
4
EXTRACURRICULAR ACTIVITIES
Rows
NAME OF ORGANIZATION
9
10
11
12
YOUR ROLE
1
2
3
4
ACADEMIC HONORS
Rows
NAME OF ORGANIZATION
9
10
11
12
YOUR ROLE
1
2
3
4
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PERSONAL STATEMENT
*
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Using a minimum of 100 words to a maximum of one (1) page, answering the following questions:Who are you? What are your career and educational goals? How will The Pembroke Foundation Scholarship help you to achieve these goals?Personal statements should submitted in MS Word format using 12pt. font. Make sure to include your First Name, Middle Initial, and Last Name.
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ADMISSION ACCEPTANCE
*
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A copy of an admission’s acceptance letter to an accredited college or university
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CURRENT TRANSCRIPT
*
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An unofficial copy of a high school transcript showing first semeter of 12th year grades and a cumulative GPA
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FAFSA (PAGE 1 & 2)
*
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A copy of the FAFSA Student Aid Report (SAR), with page one and two ONLY, showing student's Student Aid Index (SAI), or VASA
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Student Aid Index
Pell Eligible
Yes
No
COLLEGE FINANCIAL AID AWARD LETTER
*
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A copy of the financial aid award letter/email from the college your plan to attend
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