Southward Family Scholarship Application – Pickaway County Community Foundation

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Applicant Information

Graduation Requirement(Required)

I am a graduating senior of Teays Valley High School.

Full Name(Required)

First Middle Initial Last

Permanent Address(Required)

Street Address Address Line 2 City State ZIP Code

Primary Phone(Required)

Secondary Phone

Student Email(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Parent/Legal Guardian Information

Parent Name

First Last

Parent Phone

Parent Email

Guidance Counselor Information

Counselor Name

First Last

Counselor Phone

Counselor Email

High School Academic Information

Expected Graduation Date(Required)

MM slash DD slash YYYY

GPA(Required)

Class Rank

Did you participate in a specialized area of study in high school?

Yes

Did you take the ACT, SAT or both?

SAT

ACT

ACT Composite Score

Most recent ACT test date

MM slash DD slash YYYY

SAT Composite Score

Most recent SAT test date

MM slash DD slash YYYY

College/University/Vocational School Plans

Will you be enrolled as a full or part-time student?

Full-time

Part-time

Do you plan to attend a college, university or vocational school in Ohio?

Yes

College, University or Vocational School Planning to Attend(Required)

Have you been accepted into this college, university or vocational school?

Yes

Intended major or field of study(Required)

Intended minor or specialization

Personal Achievements

Activities and Involvement (Academic organizations, extracurricular activities, athletic participation, etc.)

Organization

Number of years

Your organizational role

Organization contact name

Organization

Number of years

Your organizational role

Organization contact name

Organization

Number of years

Your organizational role

Organization contact name

Community Involvement

Volunteer experience, community service etc.

Organization

Number of years

Your organizational role

Organization contact name

Organization

Number of years

Your organizational role

Organization contact name

Organization

Number of years

Your organizational role

Organization contact name

Employment Experience

Employer

Number of years

Position held

Employer

Number of years

Position held

Declarations

Privacy Declaration(Required)

I certify the information in this application is complete, accurate, and true. I understand that any misrepresentation of the facts could be the cause for the revocation of scholarships. I further authorize release of the information contained in my application and the required attachments for The Bill & June Ankrom and Milt Emerine Scholarship of the Pickaway County Community Foundation Scholarship Applications and the subsequent review of my application by the Selection Committee.

I agree to the statement of integrity and authorization to release information.

Notification of Change of Plans(Required)

I will notify the Pickaway County Community Foundation immediately, of any change in my plans to attend the school designated in my application in the semester in which I applied for The Bill & June Ankrom and Milt Emerine Scholarship.

I agree to the notification of change of plans.

Personal Information and Photo Authorization(Required)

By signing, I understand and authorize, the use of the information provided in this application and my photo, (or my child’s photo) that may be used by PCCF to publicize the scholarship program in the media or other printed materials.

I agree to the personal information and photo authorization statement.

Student's Signature(Required)

I certify that the information provided in this application is true to best of my knowledge.

Parent/Legal Guardian Signature

If applicant is under 18 years of age, parent or legal guardian agrees to the above declarations of consent.

Essay and Documents

An essay and high school transcript are required. Additional attachments are optional and are NOT required.

How do you see your major benefiting you and your future in Pickaway County?(Required)

Official High School Transcript(Required)

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 200 MB.

Letters of Recommendation

Drop files here or

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 200 MB.

Resume

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 200 MB.

Student Aid Report from FAFSA

Accepted file types: doc, docx, pdf, jpg, jpeg, Max. file size: 200 MB.

Depending on file size uploaded, the form could take longer to submit. Please do not refresh your browser once you click submit.

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