UNITED STUDENT ATHLETE INC.
EDUCATIONAL SCHOLARSHIP FORM
Application Deadline: 5:00 p.m. June 5, 2015
1.
_______________________________________________________________________
Name of Student
Age
Gender
2.
_______________________________________________________________________
Home Address
City
State
Zip Code
_______________________________________________________________________
Area Code/Phone Number
Social Security #/ Student ID #
3.
E.E.O. Code: ◊ American Indian ◊ Asian ◊ Black ◊ Hispanic ◊ White ◊ Other________
◊ Decline to State
4.
U.S. Citizen/Permanent Resident of the United States?
5.
_______________________________________________________________________
Name of High School or College Currently Attended
◊ Yes ◊ No
_______________________________________________________________________
Address
City
State
Zip Code
______________________________________________
Area Code/Phone Number
6.
University or College Qualified GPA _________ Transcript attached (required)
7.
_______________________________________________________________________
College or University Planning to Attend in 2010-2011 Academic Year
8.
_______________________________________________________________________
Probable Major or Field of Study
9.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Student’s Extracurricular Activities or Outside Interests
10.
STUDENT ESSAY: How would this scholarship assist you in reaching your goals? Two page
maximum and must be attached to this application to be considered.
11.
FINANCIAL NEED:
a. Living with
◊ Both Parents
◊ Mother Only
◊ Father Only
◊ Foster Parents
◊ Other, specify _____________________
b. Number of family members living in household _____________
c. Number of family members currently enrolled in college ___________
d. Is family receiving any form of public assistance? ◊ Yes
◊ No
e. Please list other economic conditions, if any.
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
___________________________
Nominee’s Signature
___________________________
Parent or Guardian’s Signature
(Required if student is legally a dependent.)
___________________________
Date
Applicants may attach letters of recommendation, transcripts, or other documentation in support of their
candidacy.
Please return the completed application to:
United Student Athletes, Inc.
Attention: Scholarship Committee, 6255 Pinecreek Way, Citrus Heights, CA 95621
APPLICATION DEADLINE: JUNE 5, 2012
Any application not postmarked by 5 p.m. on June 5, 2012, will not be considered for a
scholarship award.
The remainder of this form must be completed by the counselor, dean, or other qualified school official.
All questions must be answered in order for the nominee to qualify.
Reason for Recommendation.
Please review nominee’s desire for further education, potential growth and development, and leadership
and citizenship. Comments about a nominee’s academic ability may be included, if relevant, but a
superior scholastic record is not a requirement.
12.
DESIRE TO FURTHER EDUCATION
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
13.
ABILITY AND POTENTIAL
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
14.
LEADERSHIP AND CITIZENSHIP
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
15.
OTHER REMARKS
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
I hereby certify that the nominee meets all requirements of this program:
______________________________
School Official’s Signature
_____________________
Print Name
______________________________
Date
_____________________
Title
Please return the completed application to:
United Student Athletes, Inc.
Attention: Scholarship Committee, 6255 Pinecreek Way, Citrus Heights, CA 95621
APPLICATION DEADLINE: JUNE 5, 2015
Any application not postmarked by 5 p.m. on June 5, 2015, will not be considered for a
scholarship award