The Lacy Alana West Memorial Scholarship Application

THE LACY ALANA WEST MEMORIAL SCHOLARSHIP APPLICATION All applications must be submitted no later than March 19th or each year. Applications must be sent to the following address: >The Lacy Alana West Memorial Scholarship Fund< 42 Horse Fly Valley Lane Steelville, Missouri 65565

Applicants Full Name: Date of Birth

Applicants Full Address:

Home Phone Number: Cell Number: Other:

Parent(s)/Guardian(s) Name/Address

Are you currently employed at a part time job? YES NO If yes, what is your occupation

Please give employer’s name, address phone number:

List any previous part time positions you have held, as well as employer, addresses and phone numbers:

Give the name and address of at least 3 references (do not use relatives)

Are you currently a Senior at Steelville R-3 High School? YES NO

Date you will graduate from the Steelville R-3 High School

Chosen Educational Institution you will be attending after high school?

Address: Field you will be studying at this Educational Institution?

Have you applied to this Educational Institution at the time? YES NO

Have you been accepted to this Educational Institution at this time? YES NO

If you answered NO to the previous two questions, please explain

Do you expect to receive any additional Scholarships or Financial Assistance? YES NO

If YES, please list Scholarships or type of financial assistance you will be receiving:

(We do NOT require that you fill the financial information out) Number of Adults in your household working Number of Children in family still residing at home

Is this a single parent household? YES NO Approximate Total Gross Family Yearly Income:

Average Grades – Senior Year List any special achievements you were recognized for or feel you personally achieved in the past year:

You must also submit an essay containing a minimum of the following information: Your career goals, how you would plan on using this scholarship, your personal reason for applying for this specific scholarship, and your personal experience or views of teenage drinking and the impact of drinking and driving. The essay must be typed, single spaced, not to exceed one page in length.

Revised – February 2009