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1804 Scholarship Application

STUDENT PROFILE First Name: ____________ Date of Birth: ____________ Current High School: ______________________________________________ Home Address_____________________________________________________ Home Phone: ____________ Students Cell Phone: ______________ Last Name: ____________

Email Address_____________________________________________________ Parent/Guardians Name____________________________________________ Work Phone: ____________________ Cell Phone: _____________________ Parent or Guardians Email Address__________________________________

High School Honors/Awards/Activities/Employment To this application, please attach your resume/CV and be sure to list: All your important high school activities, dates of participation, awards, and offices held (include student government, sports, school publications, arts, debate and exchange programs, etc.). All public service and community service activities that you have voluntarily participated in, without pay (include projects with community organizations, environmental protection and conservation efforts, work with religious organizations, Scouts etc.) Any paid jobs held outside of school Special skills and/or talents

College Application Status What colleges/universities have you submitted applications to?

What colleges/universities have you been accepted to?

What is your connection to Haiti?

What is your connection to the Haitian Roundtable?

Application Instructions and Deadline This application, together with ALL related documentation must be received no later than March 8, 2014. Please place your name on all materials and save them as PDFs. Email your application to: attn.: Education & Scholarship Committee

Incomplete Application Packages Will Not Be Considered. No Exceptions.