2. Description:
   Awarded to a Michigan City, graduating senior in a public, private or homeschool setting who accepts his/her obstacles and or challenges while focusing on the positive aspirations of advanced education.
4. Theme
   The applicant will express, through a personal essay, what goals were achieved and what CHALLENGES and or OBSTACLES were overcome as a student. The applicant should also explain how he/she was able to serve others in the community.
6. Applicant's First Name*
7. Applicant's Last Name*
9. Applicant's Street Address*
10. Suite or Apartment Number
12. Applicant's Mailing Address
    (if different from street address)
14. City*
15. State*
16. Zip Code*
18. Primary Phone*
19. Secondary Phone
21. Primary Phone Type*

    1. Home
    2. Work
    3. Mobile
22. Secondary Phone Type

    1. Home
    2. Work
    3. Mobile
24. Applicant's Email Address*
25. Fax Number
27. Parent/Guardian's First Name*
28. Parent/Guardian's Last Name*
30. Name of School*
31. Graduation Date*
    Graduation Date
33. School Address*
34. Suite or Apartment Number
36. City*
37. State*
38. Zip Code*
40. Principal's Name*
41. School Telephone*
43. Required Essay*
    What goals were achieved and what CHALLENGES and or OBSTACLES were overcome as a student? Please also explain how your was able to serve others in the community.
45. Explain your future educational plans*
    For example: college, vocational training, etc.
47. Please list your community service involvment*
49. Please list your current extracurricular activites*
51. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
53. Electronic Signature
Leave This Blank:


55. 1. Receive an email copy of this form.
56. Email address

    This field is not part of the form submission.

57. Submit Submit and Print

* indicates a required field