SEATTLE HIROSHIMA CLUB SCHOLARSHIP APPLICATION
SEATTLE HIROSHIMA CLUB SCHOLARSHIP APPLICATION
NAME:___________________________________________________________________________________
Last First Middle
ADDRESS:___________________________________________________ Tel:________________________
__________________________________________________ Email:______________________
DATE OF BIRTH: _______________________ PLACE OF BIRTH:__________________________________
HIGH SCHOOL: __________________________________________________________________________
Name Location
CUMULATIVE GRADE POINT AVERAGE (which includes 9th, 10th and 11th grade):____________
NAME OF FATHER_____________________________NAME OF MOTHER__________________________
SIBLINGS (Names and Ages)________________________________________________________________
________________________________________________________________________________________
HIROSHIMA LINEAGE: Name of Hiroshima immigrant related to you________________________________
Please complete the following lines as you trace your family’s connection to the above named Hiroshima immigrant. Prior or Current Member of SHC? (Y or N)
Full name of parent with Hiroshima lineage________________________________________ ___________
Full name of grandparent with Hiroshima lineage___________________________________ ___________
Full name of great-grandparent with Hiroshima lineage_______________________________ ___________
Full name of great, great grandparent with Hiroshima lineage__________________________ ___________
For the following questions please feel free to submit answers on a separate sheet of paper.
SCHOOL AWARDS AND RECOGNITION:
9th_____________________________________________________________________________________
10th____________________________________________________________________________________
11th____________________________________________________________________________________
12th____________________________________________________________________________________
EXTRACURRICULAR SCHOOL ACTIVITIES:
9th_____________________________________________________________________________________
10th____________________________________________________________________________________
11th____________________________________________________________________________________
12th____________________________________________________________________________________
COMMUNITY INVOLVEMENT AND ACTIVITIES:
9th_____________________________________________________________________________________
10th____________________________________________________________________________________
11th____________________________________________________________________________________
12th____________________________________________________________________________________
NON-SCHOOL AWARDS AND RECOGNITION:
9th_____________________________________________________________________________________
10th____________________________________________________________________________________
11th____________________________________________________________________________________
12th____________________________________________________________________________________
HOBBIES AND INTERESTS:________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
EMPLOYMENT HISTORY (From grade 9 to date):
_______________________________________________________________________________________
Name/Location of Employer Dates of Employment # hrs/wk
_______________________________________________________________________________________
Name/Location of Employer Dates of Employment # hrs/wk
_______________________________________________________________________________________
Name/Location of Employer Dates of Employment # hrs/wk
COLLEGES AND UNIVERSITIES APPLIED TO:________________________________________________
_______________________________________________________________________________________
______________________________________________________ Responses to date:________________
PROPOSED DEGREE/MAJOR:_____________________________________________________________
FUTURE GOALS AND ASPIRATIONS:_______________________________________________________
_______________________________________________________________________________________
THE FOLLOWING DOCUMENTS MUST ACCOMPANY THE APPLICATION:
1. Senior high school official transcript as of the latest completed semester/trimester.
2. List of current classes and projected second term courses.
3. An essay of 200 words on the subject “What Hiroshima Means to me”.
4. At least two recommendations: one from a school official, and one from a community member.
(Recommendations from relatives will not be accepted.)
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