E. Bernice Harris Scholarship
Application Form
This form must be completed and signed by the applicant, applicant’s Shepherd and applicant’s YED Supervisor.
Falsification of any information will result in disqualification for competing in the Scholarship Competition.
Applicant Information
Applicant’s Name: _____________________________________________________
Email Address: ___________________________________
Phone Number: ( )________________________ Willing to receive text messages? ☐Yes ☐No
High School Graduation Year: ___________________
College you plan to attend: ____________________________________________________________________
Home Address: ______________________________________________________________________________
City: _____________________ State: _____________ Zip Code: _______________________
How long have you been a member? ______________________
Local Church Information
Band/Temple Number __________
Church Address: __________________________________________________________________
City: _____________________ State: _____________ Zip Code: _______________________
District: _______________________________
Shepherd’s Name: ______________________________________
YED Supervisor’s Name: ____________________________________
Local Involvement and Future Plans
In the space below or on a separate sheet, describe the applicant’s involvement with their local band.
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In the space below or on a separate sheet, describe the applicant’s college and career goals, and how they plan to
improve the church after college.
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Signatures
By signing below, you acknowledge that all information present in this form is true to the best of your
knowledge.
Applicant’s Signature __________________________________________ Date: ____________________
Shepherd’s Signature __________________________________________ Date: ____________________
YED Supervisor’s Signature __________________________________________ Date: _______________