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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Cell Phone #*Email* Enter Email Confirm Email Country of Birth* Legal Status*U.S CitizenPermenant ResidentOther (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 from 3.7 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 receiveFAFSA “EFC” 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)*Substance abuse is an epidemic that has been plaguing our community for years. Teenage drug abuse is one of the largest problems in society today and continues to grow every year. Peer pressure, low self-esteem, escape, self-medication, boredom, instant gratification and rebellion… are some of the reasons why youth turn to drugs. How do you think we as a community need to address this epidemic and what role should youth take in this effort?Please upload Required Documents belowAcademic 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: 250 MB.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: 250 MB.Release Statement and AcknowledgementConsent*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 NameBy typing my name below, I am electronically signing this application.
