Application Form

The Peggy Perry Belcher Scholarship Fund, Inc Scholarship Application

Name*
First Last
Phone Number*
Mailing Address*
Street Address Address Line 2 City State ZIP Code
Parent/Guardian Name*
First Last
Email Address*
High School or College GPA
College or University plan to attend or currently attending
Telephone Number of college or university
Major
Minor
How will this scholarship influence your life?
Church, Community and Volunteer Service and Extra-Curricular Activities
List participation in church, community and volunteer service and/or extra-curricular activities during your high school and/or college years, if applicable.
Honors and Awards
List any honors and awards received during your high school and/or college years, if applicable.
I certify that the information contained herein is true and correct to the best of my knowledge. If I am an award recipient, I give the Peggy Perry Belcher Scholarship Fund, Inc. Board of Directors and affiliates the right to use my name and picture to announce and advertise in media and social media outlets. Applicants, scholarship recipients, parents and affiliates waive any right to payment, royalties or any other consideration for the use of the images. We further hold harmless Peggy Perry Belcher Scholarship Fund, Board of Directors and affiliates of any written or print information on the applicant and/or scholarship recipient.
Signature of Applicant & Date
Upload Supporting Documents*
Drop files here or

Accepted file types: jpg, pdf, png, doc, Max. file size: 256 MB.