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Scholarship Application Form
ALL INFORMATION WILL BE KEPT CONFIDENTIAL

• First Name:
• Last Name:
• First name you prefer to be called (if different):
• Social Security Number:
• Date of Birth:
• Home Address
• Street:
• City:
• Zip:
• County:
• Cell phone:
• Email address:
• Name of parent(s) or guardian(s) with whom you live:
• Parent’s cell phone:
• Parent’s email address:
• Do you plan to work while at college?
• Full time?
• Part time?
• Work/study program?
• Name of your High School:
• Principal:
• Address
• Street:
• City:
• Zip:

• Senior Counselor’s Name:
• Senior Counselor’s Email:
• GPA:
• Class Rank:
• Class Size:
• ACT Score:
• Academic Clubs:
• Academic Awards:
• High School Offices Held:
• Community Activities:
• Golf and Other Athletics
• Average Golf Score or Handicap?
• Where do you plan to attend college?
• Have you applied for admission?
• Have you been accepted?
• What field of study do you plan to pursue?
• If selected, I authorize the Birmingham Golf Association to use my name and
  photograph, and I agree not to hold Birmingham Golf Association liable for any such use.
• Signature of Applicant
  Date
• Signature of Parent/Guardian
  Date