HBCU Week x MICHAEL S. PURZYCKI Changemaker Scholarship

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Page 1

Scholarship Eligibility

	Yes	No
Are you a U.S. citizen or legal permanent resident of the United States?

	Yes	No
Are you a high school senior? (Class of 2024)

*To be eligible for the scholarship, you must be a U.S. citizen or legal permanent resident of the United States.

To be eligible for the scholarship, you must be a current high school senior.

High School Grade Point Average (GPA) on a A 4.0 Scale (unweighted)
Please round to the nearest tenth (e.g., 2.95 and higher round up to 3.0)

If GPA is weighted, please convert your weighted GPA to unweighted. Seek high school counselor’s advice on how to convert unweighted GPA * REQUIRED PROOF OF GPA: YOUR MOST RECENT OFFICIAL SCHOOL TRANSCRIPT

To be eligible for the scholarship, you must have a 3.0 or higher GPA.

Page 2

Student Information

First Name

Last Name

Mailing Street

Mailing City

Mailing County

Mailing State

Mailing Zip/Postal Code

Mobile Phone

Personal Email

	Email	Phone
What's the best way to contact you?

Birthdate

Age

How did you hear about the scholarship?

Other

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Email

Parent/Guardian Daytime Phone

Parent/Guardian Mailing Address

Parent/Guardian Mailing City

Parent/Guardian Mailing State

Parent/Guardian Mailing Zip/Postal Code

Parent/Guardian Relationship to Applicant

High School Information

High School Attended

Student ID

	1	2	3	4
Number of years attended

High School City

High School State

I will be attending the following school in fall of 2024

	Yes	No - Undecided
Do you know what school you plan on attending?

Intended HBCU

I will be attending the following school in Fall of 2024

Do you know what school you plan on attending?

YesNo - Undecided

HBCU School State

Alabama Schools

Arkansas Schools

California School

Delaware School

District of Columbia Schools

Florida Schools

Georgia Schools

Kentucky Schools

Louisiana Schools

Maryland Schools

Mississippi Schools

Missouri Schools

North Carolina Schools

Ohio Schools

Oklahoma School

Pennsylvania Schools

South Carolina Schools

Tennessee Schools

Texas Schools

US Virgin Islands School

Virginia Schools

West Virginia Schools

Statement of Financial Need

	Yes	No
I attest that I am in need of financial assistance for my college expenses

Household Income

Please provide a Statement of Financial Need

(200 word maximum)

Intended Major

Page 3

Extracurricular School Activities Information

Please list activities, your role in the activity and the applicable dates. Click 'Add another extracurricular school activity' to enter each additional activity.

Extracurricular School Activities

Role

Start Date

End Date

Organization Information

Please list organizations you are now active in or have previously been active, your role in the organization and the applicable dates. Click 'Add another organization' to enter each additional organization.

Organization Description

Community organizations include service, volunteer and religious groups,

Role

Start Date

End Date

Recognitions Information

Please list important awards and recognitions received and the applicable dates. Click 'Add another recognition' to enter each additional recognition.

Recognition Description

Start Date

End Date

Short Essay Questions

Short personal statement

Documentation

The following items must be attached to this application in order to qualify for the review by the scholarship committee.
Your application will be returned to you if these items are not attached; no exceptions.

	Yes	No
Have you received your acceptance letter?

Proof of acceptance at an Historically Black College or University (HBCU) for post-secondary studies. A letter of college or program acceptance is required for receipt of funds.

*This can be submitted up until April 11, 2024. *All other application materials must be submitted no later than February 16, 2024.

*The Acceptance Letter can be submitted up until April 11, 2024. You will receive an email that will allow you to upload your acceptance letter when you have received it.

*All other application materials must be submitted no later than February 16, 2024.

	Yes	No
Do you have your most recent transcript?

Most recent transcript

Based on the information you've provided, your counselor will receive an email asking them to provide your most recent transcript by February 16, 2024. It is recommended that you follow up with your counselor to make sure it is completed by that date.

Provide Counselors Information

Counselors First Name

Counselors Last Name

Phone

Page 4

ACKNOWLEDGMENT AND RELEASE

I have read and understand the criteria and requirements and agree to all. I understand that lack of fulfillment of these criteria may result in loss of the award.

As a condition of scholarship receipt, I give permission to HBCU Week Foundation to use my name, photos, video imagery, video audio, interview content and other materials about me for promotional, publicity, marketing, or organizational purposes.

PARENT/GUARDIAN SIGNATURE IS REQUIRED ON THE FOLLOWING PAGE.

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