The Nat Moore Foundation Urban Scholarship Program. Invites. South Florida School Districts graduating high school seniors.

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1 The Nat Moore Foundation Urban Scholarship Program Invites South Florida School Districts graduating high school seniors to apply for its $10,000 Four-Year Scholarships ($2,500 per year for 4 years) Deadline for applying: Friday, January 31, 2014 Students must: Ø Be graduating from Miami-Dade or Broward County High Schools Ø Demonstrate financial need Ø Plan to attend a 2-year or 4-year college, or technical school Ø Have a cumulative, non-weighted GPA of 2.0 or above on a 4.0 scale Ø Demonstrate a commitment to community service To learn more and to submit applications, visit The Nat Moore Foundation s website at or contact the Foundation by at info@natmoorefoundation.net or by phone at Network With Us Find out about Nat Moore Foundation events, Urban Scholarship Program Updates, win prizes from trivia questions, and more!

2 URBAN SCHOLARSHIP PROGRAM APPLICATION PACKET CHECKLIST An incomplete application will delay the evaluation process and may result in disqualifying you from scholarship consideration. Prior to mailing your packet, please be sure to include all of the following: Completed and signed application (Pages 2 to 4) An official high school transcript, which includes most recent course work One letter of recommendation from an appropriate high school teacher or administrator on school or business letterhead Extracurricular activities listing (described on Page 4 of the application) A personal statement of words (described on Page 4 of the application) Signed Permission to Release Form (Page 5) One photograph (formal high school photograph preferred) Please mail or your completed packet for the Foundation to receive no later than Friday, January 31, 2014 to: Urban Scholarship Program The Nat Moore Foundation N.E. 6 th Avenue North Miami Beach, FL info@natmoorefoundation.net Page 1

3 Getting to Know You and Your Family URBAN SCHOLARSHIP PROGRAM APPLICATION FORM PLEASE TYPE OR LEGIBLY PRINT RESPONSES 1. Applicant Full Name: 2. Current Street Address: City: State: Zip: County: 3. Home Phone: Cell Phone: 4. Applicant 5. Parent(s)/Guardian(s) Full Name: 6. Parent(s)/Guardian(s) Permanent Address: City: State: Zip: 7. Parent(s)/Guardian(s) Home Phone: Cell Phone: 8. Parent(s)/Guardian(s) Educational Background 9. Name of High School: 10. School Address/City/Zip: 11. Graduation Date: GPA (4.0 Scale): 12. Combined Score for ACT: SAT: Continuing Education Information 13. Check all that apply: I have applied to the following college(s) or university(ies) and await their decisions: a. b. c. I have formally accepted an invitation to attend the following college or university: Page 2

4 14. Planned Course of Study/Major/Educational & Career Goals: Scholarship Needs 15. Please briefly describe your scholarship needs in the space below. Scholarship needs can include, but is not limited to, family financial situation, and the shortfall between college expenses, expected financial aid and scholarship support. Please do not go beyond the space provided. 16. Family s Total Annual Income Level: $ Number of People in Household: 17. Age of People in Household: 18. Mother/Guardian s Employer: Father/Guardian s Employer: 19. Number of siblings or household members currently enrolled in college: 20. Did your family purchase a Florida Pre-Paid College Plan? Yes No Level: 21. Did you receive a Bright Futures Scholarship Award? Yes No Level: 22. Please list all scholarships you have secured. Please include name of scholarship, amount and the duration of the scholarship (i.e. one-year scholarship or four-year scholarship): 23. What is the annual cost of the college you plan to attend? 24. Please include your FAFSA report or the financial aid letter from the school you plan to attend. Included Will send when receive Demographic Information 25. Date of Birth: 26. Gender: Male Female Page 3

5 27. U.S. Resident Status: U.S. Citizen Permanent Resident Other: 28. Ethnicity: African-American Asian (Chinese, Japanese, etc.) Latino/Latina Native American/Alaskan Pacific Islander/Filipino White/Caucasian Other: South Asian (Indian, Pakistani, etc.) Extracurricular Activities 29. On a separate sheet of paper entitled Extracurricular Activities, please describe your experience for each of the areas listed below, using the same headings/titles. Where appropriate, be as specific as possible regarding the dates, length, and extent of your activities. Be sure to type your name at the top of each page of your Extracurricular Activities listing. Community Activities and Volunteerism Honors and Awards Leadership Experience School Activities Work Experience Personal Statement 30. On a separate sheet of paper entitled Personal Statement, write a word essay describing why you should be a recipient of The Nat Moore Foundation Urban Scholarship Program. Please remember to include your full name on your photograph and each page of your scholarship application. Application Certification I certify that all the information provided in this application is true, complete and accurate to the best of my knowledge and understanding. I understand that if I have provided any inaccurate information of a substantial nature, my application will be disqualified from consideration. Furthermore, if I have already been approved for a scholarship and have been receiving scholarship funds, I will forfeit in perpetuity any future payments from the remaining balance of my scholarship not already received by the college or university that I attend or plan to attend. Applicant Signature Date Page 4

6 URBAN SCHOLARSHIP PROGRAM PERMISSION TO RELEASE FORM Student Information Release Statement By signing below, I hereby voluntarily grant my high school, college or university permission to confirm or verify my personal information to The Nat Moore Foundation Urban Scholarship Program administrators and their agents for the purpose of the Foundation s scholarship selection process and fund distribution. I also agree to hold my school, college or university blameless if the institution, in the act of verifying in good faith the information presented herein, offers information that contradicts the information I have provided, which may result in the disqualification of my scholarship application and/or the discontinuation of my scholarship payments. Applicant Name (Please Print): Applicant Signature: Date: Parent/Guardian Name (Please Print): Parent/Guardian Signature: Date: Permission to Publicize Release Statement By signing below, I hereby voluntarily grant The Nat Moore Foundation the right to use my name and likeness in any communication promoting The Nat Moore Foundation and its Urban Scholarship Program. The Nat Moore Foundation agrees to use my name or affiliation only to identify and publicize my participation in The Nat Moore Foundation s Urban Scholarship Program. I also grant The Nat Moore Foundation the right to produce and distribute any of the materials submitted in conjunction with my application. I represent and warrant that the materials submitted by me are original with me, and that the materials do not infringe any copyright or other rights in any other work. Applicant Name (Please Print): Applicant Signature: Date: Parent/Guardian Name (Please Print): Parent/Guardian Signature: Date: Page 5