SCHOLARSHIP OPPORTUNITY RECIPIENT APPLICATION Name of Scholarship Applicant___________________________________________ Age of Applicant _________ Street Address________________________________ City_______________________________ State _________ Zip Code ____________ Email Address ___________________________________________________________ Day/Evening Phone Number _____________________________________________ Which Neighborhood Watch and or community organization are you representing? ______________________________________________________________________ Explain why your are applying for the VSNC Lynchburg Local Recipient Scholarship? ______________________________________________________________________ ______________________________________________________________________ ***Will you be available for the two (2) days: Thursday, September 18, 2014 from 11:30am - 5:00pm (Included with Thursday’s conference from 6:00pm - 8:00pm is a Masquerade Dinner) and Friday, September 19, 2014, 7:30am to 5:00pm? (A local mobile tour or on-site workshops are include). Yes or No ***Please explain if you are not able to attend the full conference in 50 words or less.
See VSNC Local Informational Pamphlet or visit www.lynchburgva.gov/vsnc2014 and www.vsnc.org for detailed itinerary (sites are continually being updated- workshops offering will be posted by June) _____
_______________________________________________________________________ ***How did you hear about the scholarship? _________________________________ ***Who is your referral agency or organization- Include name of contact and correct phone number. __________________________________________________________ **Occupation ___________________________________________________________ ***Are you a Student? Yes or No If yes, which School, College or University? ______________________________Are you full or part time.? ***Do you acknowledge the scholarship is for conference fees only. Hotel and or other accommodations are not included. Yes or No Do you acknowledge the scholarship is for the conference event for youth ages 13 through adult- and no day care services are provided? Yes or No Do you acknowledge that the scholarship is on a first come first served basis per application? Yes or No If more members apply as a group there is no guarantee that all applicants will be considered
Are you willing to provide volunteer service during the conference? Yes or No. Please fill out a volunteer form: www.lynchburgva.gov/applications