Skip to content
About Us
Blog
Who We Serve
Our Roots & Mission
Board of Directors
CEO Corner
Our Family
Annual Reports
Past Newsletters
Programs
Volunteer
Workforce Development & Education
WayneLinc
Scholarship Program
Youth Leadership Program
Digital Literacy Courses
Government Civility & Leadership Academy
Public Health
Healthy Living
Infant & Maternal Health
Programs for Families
Programs for Adults
Programs for Youth
ACT Drug Free Community Coalition
Substance Use Prevention
Behavioral Health
Developmental Disabilities & Autism Services
Mental Health Services
Human Services
Resources
Events Calendar
Donate
Procurement
Careers
About Us
Blog
Who We Serve
Our Roots & Mission
Board of Directors
CEO Corner
Our Family
Annual Reports
Past Newsletters
Programs
Volunteer
Workforce Development & Education
WayneLinc
Scholarship Program
Youth Leadership Program
Digital Literacy Courses
Government Civility & Leadership Academy
Public Health
Healthy Living
Infant & Maternal Health
Programs for Families
Programs for Adults
Programs for Youth
ACT Drug Free Community Coalition
Substance Use Prevention
Behavioral Health
Developmental Disabilities & Autism Services
Mental Health Services
Human Services
Resources
Events Calendar
Donate
Procurement
Careers
Scholarship Application Form
Home
»
Scholarship Application Form
Scholarship Application
Name
*
First
Last
Last 4 digits of your social security #
*
Required
Date of Birth
*
Month
Day
Year
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Cell Phone #
*
Email
*
Enter Email
Confirm Email
Country of Birth
*
Legal Status
*
U.S Citizen
Permenant Resident
Other (Please specify)
If you answered other, please specify
A#
Permanent Residents of the USA only
Ethnicity
*
(Arab American, African American, White, Asian, Hispanic...) This info is only used to track the various ethnic groups we proudly serve . LAHC does not discriminate against any race, religion, gender or ethnic background.
Name of Academic Institution you are CURRENTLY attending
*
Academic Institution you plan on attending
*
[Note that the monetary value of the scholarship is determined based on the matching agreement (s) we have in place with various universities. If you choose to switch colleges after applying for this scholarship, the value of the scholarship received will change accordingly]
GPA
*
Please enter a number less than or equal to
5
.
Proposed Field of Study
*
Are you receiving any other scholarships or other form of financial assistance?
*
Yes
No
If you answered yes, please list any other scholarship (s) /financial assistance you are currently receiving or expect to receive
FAFSA Student Aid Index (SAI) score appearing on Student Aid Report
How did you learn about this program?
*
(LAHC staff, website, flyer, school, media outlet....)
Please list any extracurricular activities/Community Service you are enrolled in. Please be as detailed as possible.
*
Essay: (Type your 500 words essay in the filed below)
*
Describe a personal experience where you faced and overcame a challenge related to mental health. Consider the stigma surrounding mental health, especially among youth, and explain how you would promote awareness and foster understanding in your community.
Please upload Required Documents below
Academic Transcript
*
(Only scanned copies of original document will be accepted and must be in PDF or JPG format). Please DO NOT USE numbers or special characters such as (, . 1. 2, ^, &* &...) IN THE FILE NAME. We won't be able to access the file.
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Student Aid Report
IF YOU HAVE NOT RECEIVED YOUR STUDENT AID REPORT DUE TO FAFSA DELAYS, UPLOAD A WRITTEN STATEMENT TO THAT EFFECT IN LIEU OF THE STUDENT AID REPORT. (Scanned Copy must be in PDF or JPG format Only) -Please DO NOT USE numbers or special characters such as (, . 1. 2, ^, &* &...) IN THE FILE NAME. We won't be able to access the file.
Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB.
Release Statement and Acknowledgement
Consent
*
I hereby certify that all information provided on the LAHC Scholarship Application is true and complete to the best of my knowledge. I acknowledge that if I am selected to receive a scholarship, it is my responsibility to understand the requirements of the specific scholarship. The released education records and all other information attached to this application will be used for the purposes of evaluating my eligibility to receive scholarships, correspondence with scholarships donors, academic institutions, and press releases relating to scholarships recipients. I expressly authorize LAHC to disclose my education records for these purposes. All submitted information becomes property of LAHC and will not be returned to the scholarship applicants. Additionally, I give LAHC permission to use my Photograph /video for the purpose of publicity associated with scholarships awarded. This release is intended to discharge any and all claims and demands arising out of or in connection with the use of photography/video in which my image appears, including any and all claims for libel or invasion of privacy. I hereby grant LAHC the ownership and full use of any photographs/videos that are taken.
I agree to the privacy policy.
Electronic Signature of scholarship applicant: First-Last Name
*
By typing my name below, I am electronically signing my application.
Electronic Signature of Parent/ Legal Guardian if student is under the age 18: First-Last Name
By typing my name below, I am electronically signing this application.