Scholarship Application Form

* Required Information

Last Name*

Middle Name

First Name*

Gender*

Male

Female

Date of Birth*

Nationality*

Permanent Address Number*

Permanent Street Address*

City*

State*

Zip Code*

Telephone Number*

E-mail Address*

Emergency Contact Name*

Relationship*

Address*

Telephone Number*

E-mail Address*

High School Attended*

Grade Point Average (Cumulative)*

Proposed College/Course of Study

CANDIDATE PROFILE

Full Name*

Contact Address*

Phone Number*

Parents/Guardian*

High School Attended*

University/College Attending*

Course of Study*

Interests*

Future Goal(s)*

PHOTOGRAPHY CONSENT FORM/RELEASE

I, hereby grant permission to Udoka Women’s Association of Southern California to take photographs and/or digital images of me for use in news releases and/or educational materials. These materials might include printed or electronic publications, Web sites or other electronic communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of Udoka Women’s Association of Southern California.

Date

Name of Adult Subject*

Address *

City *

State*

Zip *

RELEASE FOR MINOR CHILDREN (Under 18)

I, parent or official guardian of hereby grant permission to Udoka Women’s Association of Southern California to take photographs and/or digital images of my child for use in news releases and/or educational materials as follows: printed publications or materials, electronic publications, or Web sites. I agree that my child’s name and identity may be revealed in descriptive text or commentary in connection with the image(s). I authorize the use of these images without compensation to me. All negatives, prints, digital reproductions shall be the property of Udoka Women’s Association of Southern California.

Date*

Name of Parent or Guardian *

Address *

City *

State *

Zip *

Please attach a copy of your Admission Letter on the School Letterhead*

Please attach a copy of your official Transcript*

Please attach a copy of applicant's photo*

Have you uploaded the following documents?