Freeport Lions Club: January 2015

Copy the text on this page. Paste into a Word document. Print for completion. Submit/email to Lion Terry Anderson, Lions Scholarship Committee, andersontg @aol.com, (815) 235-0834

FREEPORT LIONS CLUB - “WE SERVE”

$1000.00 SCHOLARSHIP / 2015 – 2016 / APPLICATION FORM

(STUDENT MUST ATTEND HIGHLAND COMMUNITY COLLEGE 2015-2016)

FOR YEAR 2015 GRADUATING SENIORS FROM A FREEPORT HIGH SCHOOL.

1. Name: __________________________ Birth Date: _____________ Phone: _____________

2. Address:_____________________________________________________________________

Street / PO Box City State Zip

3. Father: _____________________________ Mother: _______________________________

Address:_____________________________ __________________________

Occupation: __________________________ _______________________________

Employer: __________________________ _______________________________

Family Income (combined in 2014): $_______________

Custodial Parent (s): __________________________________________________________

4. Number of Children in Family (Including Self): _____________ (List name(s) & ages)

_____________________________________________________________________________

5. Brothers / Sisters currently attending college or Vocational / Technical School: (List name(s)

ages, & college / school)

_____________________________________________________________________________

6. List Extra-Curricular high school, community, and church activities.

_____________________________________________________________________________

7. High School: _________________________ Rank in Class: ______Out of _______ Students.

ACT score (highest): ___________

8. List any Family Member(s) or Relative(s) who are in a Lions / Lioness Club or who volunteered to

help for Lions/Lioness Club Activities:

____________________________________________________________________________

9. Attach letter of recommendation from a non-relative, i.e. Teacher, Minister, Priest, etc.

10. Type or print in 200 words or less (on reverse side or attach separate sheet):

A. Why you applied.

B. Characteristic(s) about yourself that distinguish you for selection.

C. How you feel your chosen field of study could make a difference to serve others.

I have read “Basic Requirements for Eligibility” information sheet; I meet those requirements;

and I have answered all questions completely on the “APPLICATION FORM”. All the

information submitted is correct.

Applicant Signature: ________________________________________ Date: _______________

Parent Signature: ___________________________________________ Date: _______________

FREEPORT LIONS CLUB

Question #10 (200 words or less):

____________________________________________________________________________________

Membership Info - Contact Joe Sarafini (815) 275-8737 or Terry Anderson (815) 566-7977

Friday, January 16, 2015

2015 - 2016 Club Scholarship Application

2015 Car Show Planned