The Leo Lucas Minority Stipend Program

Application 2010-2011 Due: February 4, 2011

Personal Information
Name First Last
Address
Street Address

Address Line 2

City

Postal / Zip Code

State
Home Phone - (###) - ### ####
Email
Date of Birth / MM / DD YYYY
Social Security Number
Educational Information
Name of High School
Address
Street Address

Address Line 2

City

Postal / Zip Code

State
Telephone Number - (###) - ### ####
High School G.P.A.
Post Secondary School(s) Applied to
Possible Major
Minor
Additional Information
High School Extracurricular Activities (sports, clubs,part-time job, ect.):
Special Recognition (offices held, organizational memberships, awards, ect.):
Other Scolarship Awards you anticipate this year (include title and award amount):
Have you applied for college/university financial aid? Yes No
Letters of Recomendation - Please ask two individuals (not related) to provide a letter of recomendation that includ a candid opinion of you. We suggest that comments include the following: length of acquaintance; your relationship, general and special abilities; and present and potential leadership qualities.
Letter(s) of Acceptance - Student Will be required to provide a letter of acceptance to an accredited post-secondary institution of higher learning prior to award conferral.
Official Transcript - an official transcript initiated and dated by the high school guidance counselor must be provided.
Parent or Guardian Information
Marital Status of Parent(s) or guardian(s)? Single Married Divorced Separated Widoded
Mother/Guardian's Information
Name First Last
Address
Street Address

Address Line 2

City

Postal / Zip Code

State
Home Phone - (###) - ### ####
Place of Employment
Occupation
Father/Guardian's Information
Name First Last
Address
Street Address

Address Line 2

City

Postal / Zip Code

State
Home Phone - (###) - ### ####
Place of Employment
Occupation
Did either of your parents ever attend college? Yes No
Father/Guardian's Signature
Mother/Guardian's Signature
Autobiographical Statement Please attach a word document with an autobiographical statement of approximately 600 words that includes a paragraph about your demonstrated financial need. This essay may address such topics as how your African-American Heritage has influenced your personal or academic goals; how ou have overcome personal or academic challanges; or how you have contributed to your community and what you have learned.
Applicant Checklist All of the items listed below must be completed for an applicant to be considered. Any incomplete applications will be disqualified.
Please check that you have included the following: Autobiographical Statement Two Letters of Recomendation Letter(s) of acceptence Copy of Transcripts Initiated by a Guidance Councelor
Applicant Authorization Release By checking the Box below I authorize the Ohio Black Caucus of School Board Members to release transcripts, letters of recommendation, scholarship applications, and accompanying documents to scolarship donors and to publicize my scholarship award should I be a recipient. I Accept

The Leo Lucas Minority Stipend Program

The Leo Lucas Minority Stipend Program

Personal Information

Educational Information

Additional Information

Parent or Guardian Information

Mother/Guardian's Information

Father/Guardian's Information

Applicant Checklist All of the items listed below must be completed for an applicant to be considered. Any incomplete applications will be disqualified.