ROGER HALEY MEMORIAL SCHOLARSHIP

APPLICATION

Personal Information:

Name of Applicant:_________________________________________________

Home Address:____________________________________________________

City:_______________________ Zip Code:______ Phone:_(____)___________

Mailing Address ( If different from above):

Street:___________________________________________________________

City:_______________________ Zip Code:______

Email: (optional):___________________________________________________

Date of Birth:_______________

Parental Information.

Father’s Name:____________________________________________________

Father’s Occupation:________________________________________________

Mother’s Name:____________________________________________________

Mother’s Occupation:_______________________________________________

Sibling Information.

Name:_________________ Age:________

Number of Sibling(s) in college now:_____

Will you be the first in your family to attend college? (circle one) Yes No

Yearly Household Income:____________

Academic Information:

Name of High School:_______________________________________________

Address:_________________________________________________________

City:_______________________ Zip Code:_______ Phone:_(____)__________

Principal’s Name:__________________________________________________

Scholastic average for four years:______ GPA

Have you applied to a college or university? (circle one) Yes No

Have you been accepted? Yes No

List the names of the institutions where you have been accepted: ________________________________________________________________________________________________________________________________________________________________________________________________

NOTE: Official high school transcripts must be submitted to have a complete application.

1. Please attach a separate page(s) consisting of a short autobiography and include your family background and personal interests.

2. What honors, awards, or recognitions have you received?

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3. List community service projects or activities in which you have participated that have benefited your community and the number of hours spent on each project.

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4. List all jobs, sports, and/or other extracurricular activities that you have been a part of. Please include date when you started and stopped each.

5. Describe what you consider to be the single most important project or activity in which you have participated. Why is it the most important and what have you taken from it?

6. Describe your future goals that you have for yourself in 1 year, 5 years, and 10 years.

I hereby certify that the statements contained in this application are true, accurate and complete. I understand and agree that any funds I may receive from The Chula Vista Firefighter’s Foundation must be used for educational purposes and that I will provide proof of such if requested to do so.

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Signature of Guardian Date

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Signature of Applicant Date