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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