EAST LYME SCHOLARSHIP ASSOCIATION INC.



EAST LYME HIGH SCHOOL

COASTAL CONNECTIONS AT&T SCHOLARSHIP

APPLICATION FORM

All information furnished on this application will be treated as confidential and will be shredded following the completion of the scholarship process.

PRINT ALL INFORMATION

Last Name: _____________________ First Name: _____________________ Mid. Init.: ________

Street Address: ____________________ City/Town: _______________ State: ____ Zip Code: _________

Date of Birth: __________ Telephone #: _____________ (home/cell)

What school do you plan to attend? ________________________ Have you been accepted? _______

What is your planned major? ________________________________________________________

What are your career goals?

___________________________________________________________________________________________

Have you applied for other scholarships? List them, and indicate if they have been awarded to you with dollar amounts.

___________________________________________________________________________________________

___________________________________________________________________________________________

| | |

|First Year Costs |First Year Financing |

Tuition $ _____________ Parent . Relative Contribution $ ____________

Room & Board $ _____________ Grants and Scholarships $ ____________

Total $ _____________ Approved Loans $ ____________

Anticipated Summer Income $ ____________

Total $ ____________

Number of brothers & sisters: _____________ Their ages: _____________________

Number of siblings in college next year: ___________ Student’s personal savings: $____________

Note: By submission of this application, the applicant authorizes examination of the school records relating to the student.

Combined family income (adults): Financial need is one of the qualifying criterion; therefore we must request the following information:

( Under $50,000 ( $100,000 to $150,000 ( over $200,000

( $50,000 to $100,000 ( $150,000 to $200,000

COASTAL CONNECTIONS AT&T SCHOLARSHIP APPLICATION FORM - PAGE 2 of 2

(This page may be scanned or Word Processed – Do not exceed 1 page)

Essay Requirement:

Each applicant MUST submit a 300-word (maximum) essay on the following:

“What event, global or personal, in the past year

has impacted your life and how will it influence your future.”

Use Times New Roman and 12 pt. Font. Include a copy of the essay with each application.

Questions for the Applicant:

1. List any academic or other awards received during High School.

2. List any work experience, including internships, part time and summer jobs with dates of employment.

3. List all your extracurricular activities in school, church or community during the four years of high school. (Please indicate year; 9 = Freshman, 10 = Sophomore, 11 = Junior, 12 = Senior)

I certify that the information given above is accurate to the best of my knowledge:

Date:

Applicant’s Signature:

Parent / Guardian Signature:

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