Last Name

First Name

Email Address

Phone Number

Your Address

Date of birth

Current school or accredited home school program in which I am enrolled

I will be attending the following college or university in the Fall of 2024: (Proof of acceptance or current student enrollment for the above school is required prior to receipt of scholarship funds. )

Grade point average (GPA) on a 4.0 scale:

Attach proof of GPA. Your most recent official transcript is required. File InputChoose FilesNo Files ChosenAccepted file types: js, xcf. Max. file size: 1 MB

Name(s) and address(es) and phone numbers of parent(s) or legal guardian(s):

List your academic honors, awards, memberships and activities:

List your community service activities, hobbies, outside interests, and extracurricular activities.

Personal Essay - not to exceed 1000 words Your personal essay shall tell the story of a historical event (pre-1970) in Central Oregon or of a person or group who was/were instrumental in the history of Central Oregon. It shall also explain why you chose the subject matter of your essay. No matter whether you choose to tell the story of a historical event or of a person or group, the essay must demonstrate use of community resources—digital and/or archival, primary and secondary-- e.g. Bend Bulletin, letters, recorded oral histories, personal interviews with community members or staff personnel. These sources are available at the DCHS museum or museums located at Warm Springs, and Jefferson or Crook counties. The essay must demonstrate that such consultations have been pursued. File InputChoose FilesNo Files ChosenAccepted file types: js, xcf. Max. file size: 1 MB

Statement of Accuracy: I hereby affirm that all of the above-stated information provided by me is true and correct to the best of my knowledge. I also consent that my photograph may be taken and used for any purpose deemed necessary by DCHS to promote the scholarship program. I hereby acknowledge that if chosen as the DCHS scholarship winner, I must provide evidence of enrollment/registration at an accredited post-secondary education institution before my scholarship funds can be distributed. Statement of Accuracy: I hereby affirm that all of the above-stated information provided by me is true and correct to the best of my knowledge. I also consent that my photograph may be taken and used for any purpose deemed necessary by DCHS to promote the scholarship program. I hereby acknowledge that if chosen as the DCHS scholarship winner, I must provide evidence of enrollment/registration at an accredited post-secondary education institution before my scholarship funds can be distributed. I agree

Signature of scholarship applicant Entering your name here constitures a signature

Date