SCHOLARSHIP

INFORMATION

The De’Lindsey Mack Youth Empowerment Program endeavors to provide financial scholarships, student mentoring, and coaching for individuals that are pursuing a secondary education at a college or trade school. All recipients must meet the following eligibility requirements:

Submit a completed online scholarship application.
Upload a copy of a current student picture ID (name, headshot, student ID).
Upload a copy of a current class schedule (showing registration for the upcoming Fall semester).
Upload a 500-word personal essay answering the question provided in the application.
Upload transcripts from Junior year (fall and spring semesters).
Upload 2 letters of recommendation (professional, personal or religious).

Personal Information

Student Full Name

Parent or Guardian Name

Student Phone Number

Parent or Guardian Phone Number

Student Birthday

Month

Day

Year

Multi-line address

Country/Region

Address

Address - line 2

City

Zip / Postal code

Education Information

School Name

Conduct Grade

Excellent

Satisfactory

Proof of Conduct Grade

(examples: Progress Report, Report Card, Weekly Report)

Personal Disclaimer

I hereby give permission to members of De’Lindsey Mack Youth Empowerment Program to access my academic and conduct records for the sole purpose of determining my eligibility. I understand that this waiver of my Family Rights and Privacy Act (The Buckley Amendment) rights to confidentiality applies to enrollment and transcript information, including my grade point average, as well as financial aid information. I also understand that this waiver will remain in effect so long as I remain enrolled at my University/College, or until such time as I revoke this waiver by informing the De’Lindsey Mack Youth Empowerment Program, whichever is sooner. I also attest that the foregoing application information is correct and true to the best of my knowledge.

Check below to indicate that you have read and agree with the acknowledgement above.

Yes, I agree to the above statement.

Yes

If I am a recipient of the DMYEP Break the Cycle Bike-a-Thon, I give permission to have my picture posted on the site as a recipient.

Yes, I agree.

No, I do not agree.

Parent or Guardian Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.

Signature grants permission to DMYEP for the screening of a minor.