EDUCATION FUND SCHOLARSHIP

Winifred Crawford Dibert Boys & Girls Club of Jamestown

Education Fund Scholarship and Tony LeVoie Scholarship 2023 Application Form

(Complete ONE application to apply for either/both scholarships.

Submission Deadline Friday, May 12, 2023 5PM)

EDUCATION FUND SCHOLARSHIP _____________ TONY LE VOIE SCHOLARSHIP

Full Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Gender*

E-mail*

Phone Number*

Area CodePhone Number

Cell Phone Number

Area CodePhone Number

______________________________________________________________________________________________________

Parent or Guardian Name*

First NameLast Name

Parent or Guardian Address if different*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

______________________________________________________________________________________________________

High School*

Graduation Date*

Guidance Counselor Name*

First NameLast Name

Upload a copy of your High School Transcripts if available.

Upload Your Transcripts

Upload your Transcripts

You can also have your Transcripts mailed in by your Guidance Counselor.

Send to:

Boys & Girls Club Jamestown, NY

62 Allen St

Jamestown, NY 14701

Please check the box below if you are using that option.

Mailing Transcripts

I'll have my Transcripts mailed in.

______________________________________________________________________________________________________

College or School Where Applying*

College or School where accepted and planning to Attend

College Major/Minor

Career Plans*

List all Years of Boys & Girls Club of Jamestown Membership

Current Boys & Girls Club Member

YesNo

Have you ever worked in a Boys & Girls Club

YesNo

List the Activities and Dates you were involved in at the Boys & Girls Club

______________________________________________________________________________________________________

Please list all school related scholastic and extra-curricular activities in the spaces provided below.

Enter information about the activity the number of years involved and any offices held.

1

2

3

4

Please list any awards or honors received for the activities listed above.

Awards/Honors

______________________________________________________________________________________________________

Please list all civic (non-school related activities) in the spaces provided below.

include the Activity, the number of years involved and any Office held.

1

2

3

4

Please list any Awards or Honors received for your civic activities listed above.

Awards/Honors

Please include any other pertinent information about yourself that exemplifies character and leadership.

In the box below please write an original essay up to 150 words citing your educational goals.

Please include why you have decided to continue your education, your career goals, and how this scholarship will help in attaining your plans.

If mailing in your application please attach your essay to this application.

If you you'd like to send in your essay in another format you can use the essay upload option below.

Upload Your Essay

Essay upload

By checking the box I certify that all information is accurate to the best of my knowledge.*

I certify

Application must be returned by Friday, May 27, 2022 5:00 pm