2015 Change for Change
Student Application Form
IMPORTANT:
A completed application includes, the below application, an official transcript, and the
letter of recommendation. All documents should be emailed to Quantá Taylor at
culyp.collegiate-affairs@cul.org. If you are unable to scan and email the three parts of the
application, please email Quantá and arrangements can be made for a hardcopy of your
application to be dropped off or picked-up.
Keep a copy for your records.
***Application Must Be TYPED***
High School: Click here to enter text.
First Name:
Middle Initial:
Last Name:
Enter Text Here.
Enter Text Here
Enter Text Here
Email Address: Click here to enter text.
Phone Number: Click here to enter text.
Parent Contact
Parent Full Name: Click here to enter text.
Parent Best Phone: Click here to enter text.
Parent Email: Click here to enter text.
Parent Place of Occupation and Title: Click here to enter text.
Parent Full Name: Click here to enter text.
Parent Best Phone: Click here to enter text.
Parent Email: Click here to enter text.
Parent Place of Occupation and Title: Click here to enter text.
Extracurricular Activities
List the top five (5) activities in which you have been involved and provide a description of your
contribution to that activity. Activities can reflect participation in school, church, community,
and civic functions or a personal talent/hobby during the 9th, 10th & 11th grades. Your
description should include: what responsibilities you assumed, what was the importance of your
role, how much time you committed to the activity and how often you participated. Do not
abbreviate activity names.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Activity: Click here to enter text.
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Activity: Click here to enter text.
Contribution: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Service
List your top five (5) volunteer or paid service. Explain your specific responsibilities and the
impact these experiences have had on your awareness, growth, and development. In doing so,
you will be able to demonstrate the depth and breadth of your commitment to others. Indicate
time involved (hours), frequency (once a week, one time only, etc.) and how long you have been
providing the service.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Activity: Click here to enter text.
Contribution: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Grades Involved: Click here to enter text.
Honors, Awards, and Achievements
List top five (5) awards received for school activities or from outside organizations. This should
reflect honors/awards received during the 9th, 10th & 11th grades. Do not abbreviate the name
of the organization granting the award. Awards received multiple times should be listed
collectively. Describe each honor/award and explain the importance of it.
Award: Click here to enter text.
Description: Click here to enter text.
Award: Click here to enter text.
Description: Click here to enter text.
Award: Click here to enter text.
Description: Click here to enter text.
Award: Click here to enter text.
Description: Click here to enter text.
Award: Click here to enter text.
Description: Click here to enter text.
Year(s) Received: Click here to enter text.
Year(s) Received: Click here to enter text.
Year(s) Received:: Click here to enter text.
Year(s) Received: Click here to enter text.
Year(s) Received: Click here to enter text.
Writing Entry
In 500 words or fewer, please respond to one of the prompts below. Be sure to fully address
all questions and/or considerations posed in the prompt you select; points will be deducted
from your score if you fail to do so. The diction and tone of your response should be
appropriate for the topic you select. Also, take into consideration the potential audience and/or
readers of your entry. Your entry must be typed and double-spaced. Failure to follow
directions will result in a loss of points.
Writing Entry Prompt Selection: Click here to enter text.
Writing Entry:
Click here to enter text.
By submitting this scholarship application, the applicant declares the information provided
to be true, accurate and complete. The student also grants the organization permission to
verify the information reported by obtaining documentation as needed. WARNING:
Providing false information may result in disqualification of the student's application.