AASC Scholarship Form

Step 1 of 2

Name *

First

Last

Address (Permanent Residence) *

Address Line 1

Address Line 2

City

State

Zip Code

Phone *

Email *

Sponsoring Safety Organization (Please click in box for dropdown menu) *

Are you an employee of this safety organization? *

If yes, please list the name and relationship. If no, please enter "none" in the provided box *

If no, is a family member an employee or Board Member affiliated with this safety organization?

If no, you or a family member must be employed by an organization that is a current member of your sponsoring safety council. What is the name of the organization?

Are you an employee of this organization?

Yes, I am an employee
No, I am not an employee

If no, name of family member employed by this organization.

Relationship to family member?

Name of college/university that you attending *

College/University address *

Current Grade Level (Please click in box for drop down menu) *

List school and/or community organizations in which you have been actively involved: Name of Group and (Start/End) Dates of Participation *

List positions of leadership and start/end dates you have held in school or community organizations: *

List awards and commendations you have received, reason why and date received *

List your intended career path and specific degree or certification you are seeking. *

Please type in 500 words or less why health and safety are important in your life and in your chosen career. *

You must include with your application a copy of your most recent college transcript that shows your GPA. *

Click or drag a file to this area to upload.

The scholarship award winner will be notified by June 1. The scholarship award winner will have a $1500.00 check mailed to them at the permanent residence address above.

Date of application - (Failure to submit completed application and required documents will result in an immediate disqualification) *