APPLICATION
FLOYD-LYON  MEMORIAL  KIWANIS  SCHOLARSHIP

INSTRUCTIONS
Please fill out the application completely. Place the application form in a folder along with the following pages: 
a.	A typed essay, not to exceed one double-spaced typed page, outlining your plans for further education and explaining why you want this scholarship.  
b.	Two completed reference forms — one from a high-school faculty member and one from 
             employer, community leader, or family friend.
				     
APPLICATION DEADLINE:   Applications must be returned to your high school Guidance                                             Office by the end of the school day on Friday, March 05, 2021   	
	                                                
APPLICANT’S NAME: _____________________________________________ High School _____________________

Address: __________________________________________________________________  Date of Birth: ____________________________

City and State: ______________________________________________________________ Phone: _________________________________________

Mother’s name: _________________________________________________________________________________________________________    Occupation: _____________________________________________________________________________

Father’s name: ___________________________________________  Occupation: ____________________________________________________________________________

College/Tech/Vocational school:  _______________________________________Have been accepted?  Yes __  No ____

Major/Area of study: _________________________________________________Tuition Cost: ___________________________________________________ 

          EXTRA-CURRICULAR  ACTIVITIES   AND AWARDS  RECEIVED    (List only major activities and awards): 
                       CLUBS	        CIVIC ORGANIZATIONS	                      AWARDS

			

       OTHER SPECIAL AFFILIATIONS AND INTERESTS:	                    EMPLOYED BY:

		
SOURCES OF INCOME FOR COLLEGE COST AND THE AMOUNT FROM EACH SOURCE:

Amount Parents will contribute:________________________________________________________________________

Amount applicant will contribute: ______________________________________________________________________

Other Scholarships:__________________________________________________________________________________

Other sources, please list: _____________________________________________________________________________