High School Scholarship Application Form

* Required Information

Name *

Phone Number *

Email *

Date of Birth *

Gender *

Male

Female

Other

Other Gender

Address

Street Address *

Street Address Line 2

City *

State *

Zip Code *

High School Name *

High School Address

Street Address *

Street Address Line 2

City *

State *

Zip Code *

Current Grade Level *

Expected Graduation Date *

Cumulative GPA *

Why should you be chosen as one of the scholarship recipients? *

Are you or Parents/Guardian a current customer at Valley Medical Pharmacy?

Yes

Which Valley Medical Pharmacy do you shop at?

Brawley

Calipatria

Do you have a Family Member (Near or Distant) that currently works or has worked in the past at Valley Medical Pharmacy?

Yes

Full Name

Position

List your extracurricular activities, including sports, clubs, and organizations

	Name	Position/Role	Duration
Activity 1
Activity 2
Activity 3

List your community service activities and volunteer work

	Organization	Position/Role	Duration
Activity 1
Activity 2

List any awards or honors you have received

	Name	Description	Date
Award 1
Award 2

Parent/Guardian *

Parent/Guardian Occupation *

Household Income *

Less than $20,000

$20,000 - $50,000

$50,000 - $100,000

More than $100,000

Academic Reference

Name *

Position *

Contact Information *

Personal Reference

Name *

Position *

Contact Information *

Applicant's Declaration

I hereby declare that the information provided in this application is true and accurate to the best of my knowledge. I understand that any false information may result in the disqualification of my application.

Applicant's Signature *

Clear

Date Signed