Leadership Program Application

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CURT GREENE MEMORIAL SCHOLARSHIP APPLICATION

Sponsored by the Harness Horse Youth Foundation (Please read Greene General Information page before completing this application)

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands

Phone*

Email*

Father's Name*

Father's Occupation*

Mother's Name*

Mother's Occupation*

Number of Siblings*

Number of Siblings in College*

Current Year in High School or College*

College you are/will be attending*

Degree you will be pursuing*

Grade Point Average*

SAT or ACT scores*

Have you completed the FAFSA for the upcoming year?*

YesNo

If yes, did you qualify?

YesNo

List all scholastic honors and achievements you have received in the past 4 years*

List sports, groups, clubs, community and/or volunteer activities you have participated in the past 4 year*

Work Experience

Company*

Date From*

MM slash DD slash YYYY

Date To*

MM slash DD slash YYYY

Hours Per Week*

Hourly Rate*

Company*

Date From*

MM slash DD slash YYYY

Date To*

MM slash DD slash YYYY

Hours Per Week*

Hourly Rate*

How do you plan to finance your college expenses for the upcoming year? Please be specific.*

What scholarships have you applied for in the upcoming year? If you have received any scholarships to-date, provide scholarship name(s) and amount(s).*

How much of your college expenses will be covered by personal or family contributions?*

Are there any unusual family or personal circumstances that you would like the selection committee to consider which have affected your school activities, work experience or achievements? (100 words or fewer)*

What are your career goals and ambitions? (250 words or fewer):*

[VIDEO QUESTION] How has your association with harness racing been a positive influence on your life? (2 to 4 minutes in length)*

Max. file size: 2 GB.

Names of Letter of Reference*

Names of Letter of Reference*

*

I hereby give the Harness Horse Youth Foundation permission to utilize this information for the purpose of public relations. I certify that I am a full-time student and will use this scholarship toward expenses for my educational expenses. By signing this application, I certify the above information is complete and accurate to the best of my knowledge. Falsification of information may disqualify me from consideration of a Harness Horse Youth Foundation scholarship. Upon submission, all application materials are the property of the Harness Horse Youth Foundation.

Upload Documents*

Drop files here or Select files

Max. file size: 2 GB.

Signature of applicant*

Date*

MM slash DD slash YYYY

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