Metro-Louisville PFLAG
Scholarship Award Application
PFLAG Mission Statement
PFLAG promotes the health and well-being of gay, lesbian, bisexual
and transgendered persons, their families and friends through:
support, to cope with an adverse society; education, to enlighten an
ill-informed public; and advocacy, to end discrimination and to secure
equal civil rights. Parents, Families and Friends of Lesbians and Gays
provides opportunity for dialogue about sexual orientation and gender
identity, and acts to create a society that is healthy and respectful of
human diversity.
Application Requirements
If the following materials are not received then your application will be
considered incomplete and will not be considered for the award.
1.
2.
3.
4.
Completed application form.
Completed questionnaire.
High School/GED or Post-secondary transcript. (sent by school)
Two (2) signed letters of recommendation. (sent by references)
Application Submission
Completed applications should be mailed to the address below and
must be post-marked no later than February 28th.
Metro-Louisville PFLAG
Scholarship Selection Committee
PO Box 5002
Louisville, KY 40255-0002
Metro-Louisville PFLAG
Scholarship Award Applicant Information
Please type or print clearly. All information will be kept strictly
confidential. This page must be returned with your application.
Applicant Information
Name:___________________________________________________
Address:_________________________________________________
City/State/Zip:____________________________________________
Phone:____-____-_______
DOB:___/___/______
Gender:______
Social Security Number: _____-_____-_______
Intended or Current Institution:_______________________________
Metro-Louisville PFLAG
Scholarship Award Questionnaire
Please type or print clearly. If your answer requires more space please
include your complete answer on a separate sheet of paper, please
reference the question on the separate sheet of paper. Include any
separate sheets of paper with your application. All information will be
kept strictly confidential. These pages must be returned with your
application.
Applicant Information:
Name:___________________________________________________
1. What is the name and address of the school you plan to attend, or
are currently attending? What is your current admission status
(planning to apply, applied, awaiting a response, accepted for
admission.)?
2. How do you plan to finance your education?
3. What jobs or on-going volunteer positions have you held? What
have you gained from these experiences?
Metro-Louisville PFLAG
Scholarship Award Questionnaire
(Page 2)
Applicant Information:
Name:___________________________________________________
4. What are your interests, hobbies, or extracurricular activities?
Choose one and tell how it has affected your life.
5. What would you like to be doing ten years from now and how do
you plan to achieve this?
6. What achievement or accomplishment has made you especially
proud?
7. How has being, or knowing someone who is,
gay/lesbian/bisexual/transgender affected your life?
Metro-Louisville PFLAG
Scholarship Award Questionnaire
(Page 3)
Applicant Information:
Name:___________________________________________________
8. Please list some of the groups or activities you are, or have been,
active with in the GLBT community. Include names, addresses, and
telephone numbers.
9. Is there anything else you would like to tell us?
Metro-Louisville PFLAG
Scholarship Award Reference Information
Please type or print clearly. All information will be kept strictly
confidential. This page must be returned with your application.
You are required to have two (2) adults write letters of
recommendation and mail them to the Scholarship Selection
Committee at the address listed on the bottom of the page. Include
one (1) family member if possible. List the name, address, and phone
number of both of your references below:
Reference #1
Name:___________________________________________________
Address:_________________________________________________
City/State/Zip:____________________________________________
Reference #2
Name:___________________________________________________
Address:_________________________________________________
City/State/Zip:____________________________________________
Please advise your references mail your letter of recommendation to
the following address no later than February 28th:
Metro-Louisville PFLAG
Scholarship Selection Committee
PO Box 5002
Louisville, KY 40255-0002
Metro-Louisville PFLAG
Scholarship Award Transcript Information
Please fill out this form and give it to your high school or postsecondary institution registrar so that transcripts will be received by
the deadline. Do not return this form directly to the PFLAG Scholarship
Selection Committee.
Applicant
Applicant’s Name:__________________________________________
Date of Birth:___/___/_____
Registrar
The above individual has applied for a PFLAG Scholarship. Please send
an official copy of her/his transcript to the address below no later than
February 28th:
Metro-Louisville PFLAG
Scholarship Selection Committee
PO Box 5002
Louisville, KY 40255-0002
A release of information is provided below:
Release of Information
I, ______________________________, authorize the release of
transcripts to the Metro-Louisville PFLAG Scholarship Selection
Committee.
Signed:_______________________________
Date: ___/___/_____