OFFICIAL APPLICATION FORM

L.S.C.A. SCHOLARSHIP PROGRAM

DEADLINE POSTMARKED BY MAY 7, 2004

I. L.S.C.A. INFORMATION:

MEMBER'S NAME____________________________

SCHOOL:___________________________________

HOME ADDRESS:____________________________

____________________________

HOME PHONE NUMBER:______________________

YEARS AS L.S.C.A MEMBER:______

IS THIS STUDENT A _____PLAYER OR _____FAMILY MEMBER OF L.S.C.A. MEMBER?

(check one)

II. APPLICANT INFORMATION:

NAME:_____________________________________ AGE:________

SCHOOL:________________________________________________

SCHOOL ADDRESS:_______________________________________

HOME ADDRESS:_________________________________________

HOME PHONE:______________RELATION TO LSCA MEMBER_____________

GRADE POINT AVERAGE:____________

(Based on 4.0 scale; 4 decimal places; through previous semester)

ACT SCORE:________ SAT SCORE (if applicable)________

FINANCIAL AID CURRENTLY RECEIVING (if applicable)___________________

III. INVOLVEMENT:

HIGH SCHOOL OR POST HIGH SCHOOL ACTIVITIES: (CLUBS, SPORTS, ANY

EXTRACURRICULAR ACTIVIES): _____________________________________

__________________________________________________________________

__________________________________________________________________

__________________________________________________________________

(INVOLVEMENT CONTINUED)

HIGH SCHOOL OR POST HIGH SCHOOL HONORS (List any awards or honors received...be specific)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

COMMUNITY ACTIVITIES: (Involvement outside of school)

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

IV. POST GRADUATE PLANS:

COLLEGE OF CHOICE (OR CURRENT COLLEGE):________________________

MAJOR:____________________________________________________________

V. OTHER SCHOLARSHIPS:

APPLIED FOR:______________________________________________________

RECEIVED:_________________________________________________________

VI. WRITTEN SUMMARY: IN ONE PARAGRAPH, PLEASE STATE REASONS YOU BELIEVE THAT YOU QUALIFY FOR THIS SCHOLARSHIP AND SHOULD RECEIVE IT.

SIGNATURE OF APPLICANT:___________________________________________

COACHES SIGNATURE:_______________________________________________

DATE:________________