APPLICANT'S NAME: |
|
LAST
FIRST
MI
|
|
APPLICANTS ADDRESS:
Parents
email
address_________________________________________________________________
|
| STREET NUMBER AND NAME |
| CITY / STATE / ZIP CODE |
| HOME / CONTACT TELEPHONE
#: (
)
GRADE/AGE:
/ |
FIRST
TIME SAT
CURRENT
GPA:
OVERALL
GPA:
YES
/ NO |
HIGH SCHOOL ATTENDING: |
HIGH SCHOOL COUNSELOR OR MENTOR: |
STUDY AREAS OF INTEREST (IF
DECIDED):
|
|
NAME OF
PARENT/GUARDIAN:
(REQUIRED IF
UNDER AGE 18)
|
| ANNUAL HOUSEHOLD INCOME: $ |
By signing below, you
are
certifying that all of the above information is accurate and
true. You
are also authorizing Basketball Coaches Without Boundaries, Inc. (BCWB)
to verify said information with High School Officials, if
necessary,
for the awarding of this scholarship only. By signing below
I also
permit BCWB to list my child's name in any award recognition
advertisement. BCWB will in no way use this information for
anything
other than the intended purpose of awarding this scholarship and
advertisement of it’s recipient. No individual income or
GPA
information will be released without the written consent of the student
and
parent/guardian (if under age 18). |
APPLICANT'S
SIGNATURE
Date_________________
|
| PRINTED NAME: |
PARENT/GUARDIAN
SIGNATURE:
Date_________________
|
| PRINTED NAME: |