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PERSONAL
DATA
Legal Name
of Applicant
__________________________________
(first)
(middle)
(last)
Island
Address:
________________________________________
(number)
(street)
________________________________________
(city)
(county)
(state)
(zip code)
Mailing
Address:
__________________________________
(PO Box
Number)
__________________________________
(city) (county) (state) (zip
code)
Length of
time living
at this
address___________
Home
Telephone________________
Social
Security
Number_______________
FAMILY
INFORMATION
Name of
Father___________________________
Address_________________________________
Name of
Mother___________________________
Address_________________________________
Name of
Legal
Guardian____________________
Address
if different
from
above______________
_______________________________________
EDUCATIONAL
DATA
Name of High
School______________________
Year
Graduating__________________________
Grade
point
average_________________
School(s)
- college,
university,
vo-tech - to
which you
have been
accepted.
Please state
your
anticipated
major and
attach a
copy of your
letter of
acceptance. __________________
__________________________________________
__________________________________________
EXTRACURRICULAR
ACTIVITIES -
List the clubs,
plays,
sports, etc.
in which you
have
participated
during the
last four
years.
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
ISLAND
COMMUNITY
SERVICE -
List the
documented
Island
activities
in which you
have
participated.
_______________________________________
_______________________________________
_______________________________________
_______________________________________
COMMUNITY
VOLUNTEER
SERVICE -
List the
community
services
(other than
"on the
island") you
have
participated
in during
the last
four years
and
the
estimated
hours.
_______________________________________
_______________________________________
_______________________________________
_______________________________________
_______________________________________
WORK
EXPERIENCE -
List any
jobs
(including
summer
employment)
you have had
during high
school.
Employer
Type of Work
Employment
length/
Hrs per week
_______________________________________
_______________________________________
_______________________________________
PERSONAL
STATEMENT/INTERVIEW
- Attach an essay
about
yourself to
this
application.
Include any
information
that you
feel the
committee
should know
about your
needs and
your
circumstances.
MY
SIGNATURE
BELOW
INDICATES
THAT ALL THE
INFORMATION
CONTAINED IN
THIS
APPLICATION
IS COMPLETE,
FACTUALLY
CORRECT AND
HONESTLY
REPRESENTED.
_______________________________________
(Student's
Signature)
(Date)
PALM ISLAND
ESTATES
ASSOCIATION,
INC.
P.O. BOX
5244 GROVE
CITY,
FLORIDA
34224-5244
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