Name:

Semester/Year:

Class Year:

Campus Address:

Campus Phone:

Permanent Address:

Email Address:

Cell Phone:

Student Organization Involvement (List group[s], any position[s] held, and any event[s] organized by you- include Ambassadors that work here):

Community Service Involvement (Location and number of hours per week or month):

Practical Experience Involvement (location and number of hours per week):

Workshops and/or Retreats Attended (Include Topics and Dates):

Other Leadership Involvement this semester:

Plans for future leadership involvement:

I understand that my scholarships is renewable based upon my co-curricular and leadership involvement as well as maintaining a 3.0 GPA for leadership scholarships and a 3.5 for Daniel Webster Scholarships.

Yes        No

Date: