Eligibility
Students must meet these criteria to be eligible. Please select answer.
I confirm that I am in financial need for this scholarship
Choose One
Yes
No
This field is required
I attend Pikeland Community Unit School District #10
Yes
No
This field is required
I will be attending a college or university
Yes
No
This field is required
I confirm the field of study for education I am pursuing is in a Healthcare profession.
Yes
No
This field is required
Personal Information
Name (First, Middle, Last)
This field is required
Social Security Number
This field is required
Telephone
This field is required
Email Address
This field is required
Home Address
This field is required
City, State, Zip
This field is required
High School Attended
This field is required
County
This field is required
Length of residence in this county (years)
This field is required
Name of Parent or Guardian
This field is required
Address
This field is required
City, State, Zip
This field is required
Date and Place of Birth
This field is required
Is anyone dependent on you for support?
Choose One
Yes
No
This field is required
If yes, name and relationship
This field is required
How many family members will be attending college full-time during the next four years?
This field is required
Please list their names, relationship and years they will be attending college:
This field is required
I am planning to pursue a career as a:
This field is required
College Information
Name of college you are planning to attend
This field is required
Location of College
This field is required
Anticipated cost of the first year's tuition, room & board and books
This field is required
Financial Need Information
Check any of the applicable items below to indicate how you plan to pay your expenses not covered by the scholarship
Money furnished by family
Earnings during the summer
Student Employment
Student Loans
Other means
Please list other means
This field is required
Are you aware of other monetary awards you are receiving?
Choose One
Yes
No
This field is required
If so, please list:
This field is required
As financial need is a requirement for this scholarship, you must attach a copy of pages one and two of your parents' and your Federal Income Tax Returns.
File is required
One of the considerations for this award is financial need. If there are special circumstances that you feel the selection committee should be aware of, please describe below.
This field is required
High School Activities and Community Activities
Please list below activities in which you have participated during your high school career. (include high school activities and community activities)
This field is required
Special Honors and Awards
Please list below any special honors or awards received in high school or in the community while in high school.
This field is required
Essay
Please write below a short essay describing your career plans
This field is required
Transcript
Please upload High School transcript or have guidance office send transcript to trust@farmersstate.com (PDF files please)
File is required
Acknowledgment
I certify, to the best of my knowledge, all information given on this application is true and correct.
Date
This field is required
Signature (please type name)
This field is required