CIRCLE OF FRIENDS IMPACT SCHOLARSHIP
APPLICATION FORM

 

 

All applications are submitted online.

Date *
Date
Name *
Name
Address *
Address
Phone *
Phone
Date Of Birth *
Date Of Birth
Circle of Friends Impact Scholarship Options *
Please indicate scholarship for which you are applying. ^Applicant may apply for the Lisa C. Williams Scholarship plus one additional Scholarship.
^Applicant may apply for the Lisa C. Williams Scholarship plus one additional Scholarship.
Eligibility *
Please check the box to indicate the following:
**Third Party Verification
You must provide, with this application, the name, address, phone number and the date that you were affiliated with the Third Party entity. Third party verification may include the following non-exclusive types of entities: i.) Social Service Agencies; ii.) Foster Care Systems; iii.) Licensed Treatment Facilities; iv.) Criminal Justice Institutions; and v.) Physicians, licensed clinicians and other medical facilities.
If applicable
Third Party Name *
Third Party Name
Third Party Address *
Third Party Address
Third Party Phone Number *
Third Party Phone Number
Date Affiliated with Third Party *
Date Affiliated with Third Party
Education
Please list in order of attendance the high school, college, university or trade school that you have attended or are currently attending.
Please list in order of attendance the high school, college, university or trade school that you have attended or are currently attending
Name
Major/Course of Study
Application Requirements
Please check the box to indicate that the following requirements have been met and the appropriate documents have been attached and included in this application packet. The documents below must be included with the application. Please SCAN and SEND with photo to scholarship@cofcl.org.
Application Requirements *
Please note: Scholarship Recipients are required to participate in the Awards Ceremony to be held July 15, 2017.
Authorization
I verify that the information in this Application is true and accurate to the best of my knowledge and belief. I understand that to be eligible for the Circle of Friends: Celebrating Life Impact Scholarship, I must meet the requirements as set forth in this Application. I agree to update the information in the Application should any of the information change.
Authorization *
By checking the boxes below, you are certifying and granting COFCL the right to verify with the third party organizations and that you have complied with and completed the following scholarship requirements:
Applicant Name/Signature Verification *
Applicant Name/Signature Verification
Applicant Verification Date *
Applicant Verification Date
Parent or Legal Guardian of Applicant *
Parent or Legal Guardian of Applicant
Parent or Legal Guardian of Applicant Verification Date *
Parent or Legal Guardian of Applicant Verification Date
Parent or Legal Guardian of Applicant
Submission
By clicking "Submit Application" you hereby agree to the stipulations set forth in this contract.