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2022 Spring Gala
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Healing Circle with Dr. Tasha
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Name
*
First
Last
Phone Number
*
Email
*
Address
*
Date of Birth
*
Gender
*
Male
Female
Ethnicity
*
White / Non Hispanic
African American / Non Hispanic
Hispanic
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
Other
Race does not affect the outcome of our decision making process.
Grade
*
9th Grade
10th Grade
11th Grade
12th Grade
High School
*
School Name
GPA
*
Prospective Colleges
*
Intended Major/ Concentration
*
Extracurricular Activities (Leadership Positions Held)
*
Activities ( Includes clubs and sports )
Honors / Awards / Achievements
*
Tell us a little about yourself. ( Family, friends, schools, and special interest, community involvement, hobbies)
*
What best describes your father?
*
Deceased
Estranged
Unknown
Describe a powerful moment that you remember about your father.
*
Are you currently employed?
*
Yes
No
How did you hear about us?
*
If possible would you be willing to restore your relationship with your father?
*
Please describe the impact of being fatherless and how this scholarship will benefit your future academic goals. ( Your Essay should be between 200-300 words) High School Seniors Only!
*
This Essay is Mandatory for High School Seniors only , all others please type NA ( Not Available)
Parent / Guardian Information
*
First
Last
Home Phone
*
Cell Phone
Email
*
Parent / Guardian Email.
Website
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