Student Name

Date of Birth & Age

Sex

F M

Cumulative GPA from Transcript

Address

City/ZIP

Email

Home Phone

Cell Phone

Family yearly Income

$

Financially on your own?

Yes No

Do your parents/guardians own a home?

Yes No

Number in Household

Adults in House and Relationship

On Government Assistance

Yes No If yes, type amount $

Additional forms of income and amount, if applicable (i.e. life insurance, inheritance, trust)

Do you work?

Yes No If yes, how many hours?

Are you a ward of the Court?

Yes No Not now, but was at one time in my life

Have you ever been suspended from school?

Yes No

Have you ever been arrested?

Yes No

Have you ever been expelled from school?

Yes No Answering yes to any of the questions above does not necessarily disqualify you for consideration. We ask that you please attach a letter of explanation.

Recommender Information

This can be a teacher, counselor, school administrator, or a mentor from an organization or agency who has known you for at least one year.

Student Recommended by

Position

School or Organization

Number of years known

Address

City/ZIP

Email

Daytime Phone

Evening Phone

Best time to be reached

School Contact

Position

School

Address

City/ZIP

Email

If you have attended your current school for less than one year, list previous high school(s)

Parent/Guardian names

Parent/Guardian Daytime Phone

Parent/Guardian Evening Phone

I understand that any false information supplied will invalidate my application and will deem me ineligible to receive financial support. I certify that I am a United States citizen or permanent resident, and in order to receive any funds, I will provide my social security number and may be required to provide proof of citizenship (i.e. green card). I understand I may be interviewed on camera and that the news crew will also need to shoot other videotape of me in my daily activities. I understand some information about me may appear on the KPIX 5 website, Students Rising Above website, newsletter, brochure, and other published literature approved by the Foundation for Students Rising Above.

I have read and acknowledge the above disclaimer

I have read and will submit the additional application requirements to complete my application.