SAVANNAH STATE UNIVERSITY - CHS Scholarship Newsletter



SAVANNAH STATE UNIVERSITY

PRISM SCHOLARSHIP PROGRAM

Application Form

Name:_______________________________________________________________________________

(First) (Middle) (Last)

SSN#: _________ - __________ - __________ Date of Birth: ____________________

E-mail Address:_____________________________ Savannah State Student ID 915__________

(if applicable)

Mailing Address (All correspondence will be sent to this address):

Street Address: _______________________________________________________________________

City: ___________________ State: ________________ Zip: _________

Home Phone: ( ) __________ - __________ Cell Phone: ( ) __________ -__________

Gender: Male Female

Race/Ethnicity:

African American [pic]Asian/Pacific American (please specify) _________________________

Latino/Hispanic (please specify) ______________

Native American/American Indian (please specify tribal affiliation) ________________________

White/Caucasian [pic]Other (please specify) _________________________________

Parent/Guardian: Name: _____________________ Phone: ( ) __________ -__________

Current Student Status:

If student is currently enrolled at a college/university:

Institution: ____________________________ City: _________________ State: _____ Zip: ______

Major: _______________Credit Hours Completed: ___ GPA: ____ (Include Transcript)

Expected Date of Graduation: ______

Did you receive a Hope Scholarship? Yes ______ No______

If student is graduating from high school:

School: ______________________________ City: _________________ State: _____ Zip: _______

Have you applied for admission to Savannah State University? Yes No

Have you been admitted to Savannah State University? Yes No

Extracurricular Activities:

List any extracurricular activities, awards, special recognition, achievements in sports/athletics, special interests, hobbies, etc.

_________________________________________________________________________________

___________________________________________________________________________________

___________________________________________________________________________________

References:

Three references whom you have asked to write recommendation letters: (Current college students should submit letters from science, math, technology, or engineering faculty members. Current high school students should submit letters from the high school principal, guidance counselor and science, math, technology or engineering teachers.)

Reference 1:

Name: ____________________________________ Institution: _________________________

Street Address: _______________________________________________________

City: ________________________ State: ________ Zip: _________

Phone: ( ) __________ - __________ Email: ____________________________

Reference 2:

Name: ____________________________________ Institution: _________________________

Street Address: __________________________________________________________

City: ________________________ State: ________ Zip: _________

Phone: ( ) __________ - __________ Email: ____________________________

Reference 3:

Name: ____________________________________ Institution: _________________________

Street Address: __________________________________________________________

City: ________________________ State: ________ Zip: _________

Phone: ( ) __________ - __________ Email: ____________________________

Personal Statement:

Your personal statement (at least 300 words typed/word-processed) should address all of the following:

The STEM (science, technology, engineering or math) major in which you are interested

Your career interests and reasons for your pursuit of that career

Reasons for your choice of Savannah State University’s PRISM Program

How your personal traits, skills and abilities will contribute to your success as a PRISM scholar

How did you first become aware of the PRISM Scholarship Program? (Please select one)

___High school administrator, faculty, or staff

___Savannah State University administrator, faculty or staff

___Savannah State University current or former PRISM Scholar

___PRISM Website

___Announcements on SSU’s Channel 15 or ACCESS TV monitors located in SSU buildings

___Radio Announcement

___Letter mailed to you from the PRISM Program

___Other (specify)______________________________________________

I understand that if awarded a PRISM Scholarship, I must maintain a 3.0 GPA and participate in all activities (i.e., weekly mentoring, summer program activities, monthly seminars, presentations, mandatory meetings)

Signature of Applicant: ____________________________ Date: __________________

Checklist: ____I have signed my application

____I have included my completed application

____I have included my typed personal statement

____I have included three recommendation letters

____I have included my most recent transcript

____I have included my official SAT or ACT Scores (high school students)

Completed applications should be mailed to:

Dawn Howard

Program Coordinator

PRISM Scholarship Program

Savannah State University

P.O. Box 20089

3219 College Street

Savannah, GA 31404

Or deliver in person to Herty Hall, Room 100 (8:00am-2:00pm)

Please complete and return by April 1, 2013 for consideration for the 2013-2014 academic year.

For more information, please email howardd@savannahstate.edu

-----------------------

[pic]

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download