Name of Student:

Preferred Name:

Date of Birth:

Age:

Grade (year in school):

Parent's names::

Mailing address:

Home Phone:

Cell Phone:

Email:

Current School:

Dates attended:

Name of guidance counselor:

Current GPA or average academic grade:

Please attach copy of most recent transcript:

Past 2 schools and Dates attended:

At what school or academic support program do you plan to use the scholarship money?

Contact name and phone number at this school or program.

In the last year, have you ever been subject to disciplinary action?
Expulsion?Suspension?Detention? If yes please explain.

In the last 2 years have you been asked not to return to a team, class or school?
2 years return to a team If yes please explain.

One academic, a teacher or Guidance counselor

Address

Phone

Email

Name of person 1

Address

Phone

Email

Name of person 2

Address

Phone

Email

Please attach latest tax return.

What are the biggest academic challenges that you/ your child is facing at his/her current school?

What are the social challenges that you/your child is facing at his/her current school?

Please explain the steps you have taken, programs / services / community or state resources you have enlisted to overcome these challenges. What were the results?

Tell us about one of your important accomplishments or endeavors ( not athletic ) and what you learned about yourself.

In the next 6 months, what do you want to achieve academically and how will the Springboard Scholarship and the school/ program you have identified help you attain your goal?