* Indicates required field.

Student Name:

Address:

* Street:

* City:      * State:      * Zip:

Campus Address (if applicable):

* Telephone(s):

* Email:

* Banner ID: (8-digits)

Please complete the questions below.

* 1.) Please explain the circumstances that qualify you for this particular scholarship. Include anything you want us to know about your academic or disciplinary record. If you have demonstrated financial need, please indicate so here with a brief explanation. Preference is given to self-identified gay, lesbian, bisexual, or transgender students whose family has withdrawn financial support as a result of the student’s sexual orientation or gender identity.

* 2.) How would this award help you to continue your education at BSC?

* 3) Please describe the ways in which you have advocated for the GLBT community.

* If you receive this award, do you give permission to make the award public?
Yes, I give my permission.
No, I prefer that this award not be made public.
(This is not a condition of the award. It can be awarded without publicity. )