Required Materials & Submissions: Information Name Address City/State/Zip Code Date of Birth Date of Birth: Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Date of Birth: Day Day12345678910111213141516171819202122232425262728293031 Date of Birth: Year Year20002001200220032004200520062007200820092010201120122013201420152016201720182019202020212022202320242025 Students Email Address Students Home Phone Students Cell Phone Current School and Grade Guidance Counselors Name Guidance Counselors Email Address How did you hear about the Scholarship Program? Google or other search engine Social Media Advertising Guidance Counselor Friend A Community Based Agency Other Enter other… For Undergraduate (Graduating High School Seniors) College or University Name Intended Major for Academic Scholarship Applications (HS Seniors Only) College Tuition Cost Room/Board (if applicable) Are you a first generation college student? Yes No Are you currently employed? Yes No Parent(s) or Guardian Information Name Address Relationship Home Phone Cell Phone Employer Additional Parent or Guardian Information (if applicable) Name Address Relationship Home Phone Cell Phone Employer Required Materials Please provide the following documents: 2 letters of recommendation School transcript Student resume Copy of income tax (blackout SS number) Essay: Answer 1 of the following questions. What challenges have you had to overcome to achieve your goals and pursue your education? How did you overcome those challenges and what did you learn about your own unique leadership capabilities? How will you apply the lessons learned to help you achieve your future goals? Statement of Financial Need: Describe why you need financial assistance. How will this scholarship help you achieve your goals? Describe an event, achievement or experience that has had a strong nfluence on your life using one of the DREAMS acronyms (Determination, Realization, Enrichment, Academics, Mission or Service) as a focal point Please attach/upload all materials in one PDF file here Upload Upload requirementsOne file only.200 MB limit.Allowed types: gif, jpg, jpeg, png. Any additional files to be submitted (if applicable) Upload Upload requirementsOne file only.200 MB limit.Allowed types: gif, jpg, jpeg, png. Image File Upload Upload requirementsOne file only.200 MB limit.Allowed types: gif, jpg, jpeg, png. Document File Upload Upload requirementsOne file only.200 MB limit.Allowed types: txt, rtf, pdf, doc, docx, odt, ppt, pptx, odp, xls, xlsx, ods. If you are having issues sending your documents, they can be emailed to BDepena@unitedwayli.org. Agreement By clicking the submit button below I attest that all of the information provided in this application is complete, factually correct and honestly presented. I understand that if any of the information is found to be false, this may result in disqualification or forfeiture of the scholarship award. I understand that it is my responsibility to submit appropriate bills to United Way of Long Island for payment that will be made directly to the appropriate academic institution or vendor. I understand that my submission of this form attests to the above, and I agree to adhere to these terms. If the applicant is under the age of 18 years old, an additional signature of a parent or guardian is required. Please provide signature with material submissions, if applicable. CAPTCHA This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. Submit Leave this field blank
