Scholarship Applicant Form

Donor Scholarship Application Form

First Name: Last Name: M.I.

SSN: Phone #: E-mail:

Permanent Address: City: ST: ZIP:

County of Residence:

Race/Ethnic Background:

Asian/Pacific Islander Black Hispanic White American Indian/ Alaskan Native

What is your status? Traditional(under24 years old) Non-traditional(ages 24+)

Anticipated Enrollment per Semester:
Full-Time(12+ credits) 3/4(9-11 credits) Part-Time(6-8 credits)

Number of credits completed to date:

My expected college graduation date is Current GPA:

My major is Minor:

I plan to participate in the study abroad program. Yes No
If Yes, which program and which term? Program: Term:

Housing Plans: On Campus Off Campus(Pay rent/Mortgage)Commute(Parent's Home)

Are you a veteran? Yes No

I currently do community service or volunteer work: Yes No
If yes, Where?

List parents/Legal Guardians, siblings, or other family members that graduated from Pitt-Greensburg:
Name: Relation:
Name: Relation:

High School:

Are you a member of the Greensburg YMCA? Yes No

What, if any, athletic programs did you pursue during high school?

Do you play a musical instrument or sing? YesNo
If yes, explain:

Please list any offices held with clubs/organizations(List both in-school and community based organizations):

I agree, if selected as a scholarship recipient, that personal information from this application can be released to the donors and to the local and/or hometown newspaper.