Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Basic Information Name *FirstMiddleLastDate of Birth *Address *Address Line 1CityState / Province / RegionPostal CodeEmail *Phone Number *Education High School *Graduated? *YesNoPlanned Graduation DateEnrolled in a College? *YesNoCollegeEnrollment TypeFull TimePart TimeProof of Enrollment Drag & Drop Files, Choose Files to Upload Start DateCollege Plan & Goals Desired Degree *Goals and Objectives *In around 500 words, share why you feel you are deserving of this scholarship and your educational goals for the future. Please list special circumstances that you feel should be taken into consideration during review of the application.Financial Applicant Income *Parent Helping to Pay for College? *YesNoParent Household Size *12345For applicant’s parent householdParent Household Income *Plans for Paying for College *Please describe how you plan on paying for college tuition until completion of education.Scholarship First Time Applicant? *YesNoReceived Scholarship from Headwaters Foundation in the Past Year? *YesNoAmount Requested *Max $5,000.00Basis for Request *Provide reason for this requested amount (i.e., estimated expenses, income level, etc.)Applying for Other Forms of Financial Assistance? *YesNoHave You Already Recieved Any Financial Assistance?YesNoSourceSource 2Source 3AmountAmount 2Amount 3Statement of Agreement *Yes, I understand and accept the terms.In signing this application, the Applicant understands and acknowledges that they are from a single-parent household and meet all the eligibility requirements outlined in this application. They understand they are pursuant to all rules and regulations therein and will spend scholarship funds in accordance with information provided within this application. They also agree that all information provided here is true and accurate.Terms and Conditions *Yes, I understand and accept the terms and conditions.Applicant hereby grants permission to Headwaters Foundation the rights of their image, likeness, and story, without payment or any other consideration. They understand that their image may be edited, copied, exhibited, published or distributed and waive the right to inspect or approve the finished product wherein their likeness appears. Headwaters Foundation will only use images and video for promotional material to raise money for the Foundation.Type Full Name to Authorize *Date *Submit
