NAME

STREET ADDRESS

CITY, STATE, ZIP

BEST PHONE#

HIGH SCHOOL

HIGH SCHOOL GRADUATION DATE (mm/yy)

COLLEGE, TECHNICAL OR TRADE SCHOOL

STATE DATE (mm/yy)

SCHOOL COLORS

Select C.N. Jenkins Ministry Affliliations:

Other financing options acquired. (ex. Student Loans, Grants, & Scholarships)

Please take time to explain your hardship situation (including the situation, the need, and factors that led to the hardship):

Explain your educational and career goals and how this request (if approved) will aid in attaining those:

If the assistance is NOT awarded, will you be able to continue with your educational and career goals? If no, please explain: