HBCU Community Empowerment Initiative

CONTACT INFORMATION:

Your Full Name *

DOB *

Address *

City *

State *

Zip Code *

Is this a permanent address? *

YesNo

Mobile No.

Home Phone No.

Email Address *

SCHOOL INFORMATION:

Enrolled in College *

College Name *

Field of Study *

Anticipated Graduation Year *

PERSONAL INFORMATION:

Citizenship *U.S. CitizenU.S. Legal Permanent ResidentU.S. Legal Temporary Resident (International Students)

Ethnicity *

Gender *

REQUIREMENTS:

Assistance needed for: *FoodHousingTransportationOther

Proof of Enrollment *

Submit a proof of this semester enrollment.

Headshot *

Please provide us with a profile picture.

Note: We might use it to fundraise more scholarship awards!

Tell us your COVID-19 Story!

Using 260 words or less, tell us your background story... How COVID-19 affected you and why you deserve this Scholarship? (We might share your story to donors to fundraise more scholarship awards!)

Agreement *My name, photo, story, and other application information may be used to raise additional funds.

Print Name *

Date *

Please correct errors before submitting this form.

Fields marked with '*' are mandatory

STUDENT HARDSHIP APPLICATION FORM

CONTACT INFORMATION:

SCHOOL INFORMATION:

PERSONAL INFORMATION:

REQUIREMENTS: