Amick-Baker-Kellems F.O.P. Lodge 156 - (Scottsburg, IN)

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* HOME ADDRESS:

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DATE OF BIRTH:

* HIGH SCHOOL WITH CLASS RANK____ OF _____:

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LIST ALL FINANCIAL ASSISTANCE RECIEVED: PELL GRANT, FINANCIAL AID, OTHER SCHOLARSHIPS:

* FATHERS NAME:

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* PLEASE WRITE A SHORT ESAY ON WHAT YOU THINK COULD BE DONE TO HELP PREVENT TEENAGE DRUG AND ALCOHOL ABUSE. (APPROXIMATELY 250 WORDS OR LESS):

* DATE SUMBITTED REQUIRED TO BE BEFORE MAY 1ST OF EACH YEAR:

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