*(denotes required field)

First Name: *

Last Name: *

E-Mail Address: *

School District: *

Telephone Number: *

Street Address: *

City/Town: *

State: *

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Zip Code:

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Which scholarship(s) are you applying for?

Please check all that apply:

Jeri Bigart Memorial Scholarship (Vocational School)
Edwin Thomas Scholarship
Leon Scudder Scholarship (Only students from Honesdale, Western Wayne, Wallenpaupack, Canaan and
Damascus Christian are eligible)
Wayne County Community Foundation Scholarship
Merle and Earl “Ike” Walters and Honesdale Lions Club Vision Scholarship (Honesdale High School graduate
only, scholarship for careers in Optometry, Opththalmology and Special Education Vision Therapy)
Seelyville Union Sunday School Scholarship. (All County residents eligible - scholarships for students majoring
in theology or missionary vocations)
Dr. and Mrs. Philip G. Liu Health Care Scholarship. (All county graduates eligible. For those entering health care field)
Howard A. and Ruth W. Akers Memorial Scholarship. (All county graduates eligible. For those entering
the field of Forestry or Agri-Business)

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Family and Financial Information

Father's Name:

Father's Occupation:

Father's Employer:

Mother's Name:

Mother's Occupation:

Mother's Employer:

Family Income (Check One):

$0-10000
$10000-30000
$30000-60000
Greater then $60000

Did you have any annual income? If so how much:

Number of dependent children living at home:

Number in family members enrolled in college:

Intended College Major:

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List your three top college choices and indicate if you have been accepted:

1st Choice:

I have been accepted to this school

2nd Choice:

I have been accepted to this school

3rd Choice:

I have been accepted to this school

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Activities and Experience

Community and extracurricular activities including awards and recognitions:

Work experience, including name of employers, job title, years job held:

Any other information that you want the selection committee to consider:

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Please attach a copy of your school transcript:

Acceptable file types: doc,docx,pdf,txt,rtf.
Maximum file size: 1mb.

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We (Parent/Guardian and Student) certify that this application is accurate and complete to the best of our knowledge. We also agree that if a scholarship is awarded, the funds will be used for tuition expenses only. We (I) certify that funds will be returned to the Foundation if the scholarship recipient does not enroll in college. *