Forms - Lakeland Heroes

Name*
First Last
Application Date of Submission:*
Date Format: MM slash DD slash YYYY
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone*
Student Email:*
Graduating High school*
Current GPA*
Participating Public Service Agency
Current Household Income*
- Under $25,000
- Under $50,000
- Over $50,000
Numer in Household*
Number in College*
Have you received any other scholarships? If yes, please list scholarships received and granted amounts*
Community Services Hours Earned*
Are you currently employed? If so please list how many hours per week you work?
Selected College*
Selected Major*
In 250 words or less tell us about your experiences or individuals that have influenced your decision to pursue your chosen career and how these experiences will help you in this career choice
I affirm that my mother, father or legal guardian is actively employed with a Participating Presidents Roundtable Agency.*
- Yes
- No
We’ve discovered that student last name and parent last names are often different due to re-marriage, or raised by grandparents, or guardian, or other. So, we need to be able to contact the employee and know their name, when reaching out to them for additional information, invite, or other need.*
Employee First Name Employee Last Name
Employee Cell Phone:*
Employee Email:*