Shelton D. Redden Lodge #139
Scholarship Program
Applications close on Friday, August 28
11:59pm
Name
First Name
Last Name
Suffix
Date of Birth
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Month
-
Day
Year
Date
Applicant Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Applicant Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
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As the parent/guardian of the applicant, I hereby grant Shelton D Redden Lodge no. 139 the unrestricted right and permission to use and re-use my child’s name and likeness in any and all publications, including photograph, television broadcast, video recording, internet sites, audio-recording or any other form of electronic or print communication (the promotional materials), for its own purposes without payment or any other consideration to me or my child, in perpetuity. I understand and agree that any material produced using my child’s likeness is the property of Shelton D Redden Lodge no. 139. *Please note, if a photo release is not provided, the recipient cannot be photographed in group pictures. The pictures can be published.
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Parent Digital Signature
First Name
Last Name
High School Information
Name of School
School Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Counselor Name
First Name
Last Name
Graduation Date
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Month
-
Day
Year
Date
Cumulative GPA
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Parent Name
First Name
Last Name
Parent Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Email
example@example.com
Is any member of your family a member of Shelton D Redden Lodge no. 139?
Please Select
Yes
No
If yes, what is his name?
Institution you are attending
College, trade school, etc
Intended major or course of study
Have you been admitted?
Please Select
Yes
No
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Upload Brag Sheet/Resume
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Applicant Virtual Signature
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Parent Virtual Signature
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