The Liz Rochester Memorial Scholarship

The Greater Sandusky – Firelands Area PFLAG Chapter

Scholarship Application

Guidelines and Requirements

PFLAG will award an annual scholarship of $250.00

Payment of award will be made directly to student upon receipt of proof of enrollment.

References are required from two people (other than relatives) that know you in the community (use the forms provided).

The student must be enrolled as a full time student. The college’s or university’s definition of “full time student” is acceptable.

Term of Scholarship:  One (1) academic year.  Prior recipients are invited to apply for a second year provided they meet all eligibility requirements.

Dead Line for Application: March 25, 2007 and must be postmarked prior to midnight of that date. No applications will be considered after the due date. No Exceptions.

Application: The application must be filled out completely, and presented with all required documentation as requested in the application by the announced deadline.

We, the undersigned have read, fully understand and accept the requirements as stated.

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Scholarship Application

PFLAG of the Greater Sandusky – Firelands Area

Name: ________________________________ Telephone: (____)___________________

Permanent Address: _______________________________________________________

                                     _______________________________________________________

                                               City                              State                            Zip Code

Birth date: ______/____/________                  Social Security # _____-____-___________

High School Attended:________________________ Graduation Date (M/Y)__________

High School G.P.A.: ______________

College or University for which Scholarship is requested:

School: ______________________________ Location: __________________________

Degree Sought: ________________________ Expected date of Graduation: __________

Extra Curricular and Community Activities (List membership and participation in school and community organizations and activities.):

Work/Employment History:

Honors/Achievements (include dates.):

Write a short essay based on the subject of “Social Tolerance in Our Community”. It should be between three (3) and eight (8) pages in length, type written, double-spaced.

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Scholarship Application

Reference Form

1. How long have you known the applicant?

2. How would you describe him/her?

3. What is your evaluation of the applicant’s academic ability?

4. Are there economic or unique factors that make the applicant especially worthy of receiving scholarship support?

5. Please add any additional comments or information.

Signed _________________________ Title ______________________

Address ________________________ Phone _____________________