GEORGETTE E. WASHINGTON MEMORIAL
SCHOLARSHIP FOR ACADEMIC EXCELLENCE
APPLICATION FORM

 Read Application Requirements first.  Please supply all requested information.  Application must be completed and returned MIRACLE TEMPLE YOUTH COALITION, INC.  By August 15, 2002.  (Please print neatly.)

 Applicant’s Name:______________________________________________________________________
                                   (Last)                                        (First)                                           (MI)

 Telephone: __________________Date of Birth _________________ SSN ___________________________

 Address:_____________________________________________________________________________
                      (Street)                        (City)                         (State)                        (ZIP)

 Name of Church/Community:_____________________________________________________________

 Name of School Presently Attending:_______________________________________________________
(Please indicate elementary, middle, high school or college)

 Is your school public or private?:_______________

 Parent(s) Guardian(s) Name (if different):____________________________________________________

 Telephone of Parents/Guardian:__________________________________

 Father:____________________________________               Mother:______________________________
Address:__________________________________                Address:_____________________________
_________________________________________                 ____________________________________

 Cumulative Grade Point Average:________
(Please attach a copy of your latest report card.)

ON A SEPARATE PAGE (Middle, High  & College Applicants Only) 

Topics will change depending on Current Events

Write a two page report (double spaced) on the Electoral College (explaining what it is , the purpose and what part it played in the controversies of the past presidential election).  Read 2 articles on the subject.  Your information may come from the Internet or magazines.  Your report will contain:

 TITLE PAGE                                 SECOND PAGE                               THIRD PAGE
Your Name                                      An introduction                                A bibliography
The name of your school              A summary of articles read
Your age                                          Your opinion on the subject
                                                          A conclusion

High School or College you plan to attend:___________________________________________________

 Address___________________________________________Telephone___________________________

 

I hereby certify that all statements made herein, and on any attachments enclosed herewith, are true and correct to the best of my knowledge.  The undersigned hereby irrevocably consent to and forever authorize the use by the Miracle Temple Youth Coalition, Inc (MTYC) or anyone authorized by MTYC the absolute and unqualified right to the use of the undersigned scholarship program in any manner MTYC desires, including, without limitation, the right to use such material, etc. in any advertisement, publicity, newsletter or other publication or broadcast.  In addition, the undersigned hereby release and discharge MTYC from any and all claims and demands that the undersigned may have now or in the future, which arise out of or in connection with the use of such material.  (If applicant is under age 18 parent/guardian must sign).

 Signature:__________________    _____________________________                                                       (Applicant)                                                          (Parent/Guardian)

 Date:_____________________Date:___________________________