The Rosa Parks Scholarship Competition Entry Form
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Name ________________________________________________________________________
Local Address __________________________________________________________________
Telephone Number _____________________________________________________________
E-mail ________________________________________________________________________
Title of Entry ___________________________________________________________________
Format of Entry (CD, VHS, DVD, Essay, Etc.) __________________________________________
______ Grad Student _____ Senior ______ Junior ______ Sophomore ______ Freshman
Major ________________________________________________________________________
Hometown ____________________________________________________________________
If you are selected as a winner, would you like this published in your local newspaper? _____
My Class Schedule This Semester: |
Monday/Wednesday/Friday
|
Tuesday/Thursday
|
For Office Use Only
Entry Number __________________________________________________________________
Date/Time Submitted ___________________________________________________________
Typed Statement Attached? (circle one) Yes No
