Application for

Dr. Jerry Church Community Health Sustainer’s Award

Please, read all text fields before beginning to apply. You should not leave the page once you have started to fill out the application form. Thank you!

Personal Information

First name*

Last name*

Middle Name

Email Address*

Address*

City*

State*

ZIP Code*

Parent(s) or Guardian(s)

Guardian 1:

First name*

Last name*

Guardian 2:

First name*

Last name*

Education Information

Name and Location of High School*

Year of High School Graduation*

Grade Point Average*

I have been accepted to the following College / University:

College Name*

College City*

I will begin (or began) classes on*

Anticipated Major / Minor*

Are Parents and/or Siblings currently attending college?*

Yes

How do you plan to pay for college?

Total projected annual cost of college*

The following boxes, when combined, should total the total projected annual cost of college:

Amount paid by student*

Other accepted scholarship amounts*

Student loan amount*

Other*

Employment & Community Involvement

Are you currently employed?*

Yes

Employer & Position held*

Community & Volunteer activities*

Student &/or Community leadership roles*

Awards or Special Recognition*

Career Goals

Important: When filling out this online application, it is best that you don't leave the page or your information could be lost.

In 300 words or less, how would you define your career goals?*

Letters of Recommendation

Please upload at least one letter of recommendation: (.doc or .pdf formats only)*

Drop File Here or browse your computer

I accept the Terms

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