CHALLENGE MOUNTAIN

SCHOLARSHIP APPLICATION FORM

Use additional sheets if space provided is not sufficient.  All information will be kept strictly confidential.

APPLICANT NAME:                                                                                                                                            __________              

Last                                                                 First                           Middle  Initial                                      

ADDRESS:                                                                                                                                                 Street                                                      City                                               State                     Zip      

TELEPHONE:                                             SOCIAL SECURITY #:                                                     

BIRTH DATE: _______             ____                            

NAME OF COLLEGE YOU CURRENTLY ATTEND:                                                                                                                          ____

COURSE OF STUDY:            MAJOR                                                                  __         MINOR                                                      ____

LAST LEVEL / SEMESTER COMPLETED (e.g. sophomore / 2^nd semester):                                                                              ____

PERSONAL STATEMENT:  In one typed page or less, attach a personal statement that will give the selection committee insight as to why you are pursuing a college curriculum in recreational therapy or special education.  Discuss personal qualities related to your studies, experiences, and potential that would make you a worthy recipient, including any paid or volunteer work experiences with special needs individuals.

FINANCIAL NEED:  Please submit with your application a copy of your FAFSA Student Aid Report. 

TRANSCRIPT:  Please submit with your application an official copy of your latest academic transcript. 

CERTIFICATION:  I certify that the information provided in this application is complete and accurate to the best of my knowledge.  Falsification of information will exclude me from scholarship consideration.

Applicant Signature                                                                                _______                            Date_______________ 

SUBMISSION:  Mail the original application with attachments and two complete copies to:

                                   Sarah Allen, Program Associate

                                   Charlevoix County Community Foundation

                                   PO Box 718

                                   East Jordan, MI  49727

DEADLINE:  Completed applications must be received by April 1.