Application for PFLAG Lawrence/Topeka
                             Scholarship Award
                           2023-2024 Academic Year

                             All information is strictly confidential

Eligibility

You must be:
1.  Self-identified as gay, lesbian, bisexual, transgender, queer, or a straight ally.
2.  A resident of the state of Kansas at time of application
3.  A high school graduating senior.
4.  Applying to or has been accepted at a post-secondary or technical educational institution

Terms

 Awards are paid jointly to the student and the institution and are meant primarily for tuition and fees.  Under no circumstances will award be paid only to the student.
 
Instructions

1. Complete application and submit by May 31st to:
	Sonja Feist -- PFLAG ScholarshipCommittee 1910 SW Sieben Ct. Topeka, Ks 66611

2. Application must include a current photograph, and copy of your Kansas state driver’s license or                                                                    	state ID to prove residency.

3. Obtain a letter of recommendation, written by someone over 18 years old, from a teacher, coach, 	minister, counselor or employer.

4.  Have current transcript sent to: Sonja Feist, PFLAG Lawrence/Topeka, 1910 SW Sieben Ct., 
     	Topeka, Ks  66611

5.  Application, photograph, copy of driver’s license, letter of recommendation, and transcript must be received by May 31st to be considered for scholarship.

6. Person who receives scholarship will be announced June 9th, 2023

Applicant Information

Name:  _______________________________________ Date of Birth: _______________________
                   (Last)               (First)                      (Month)  (Day)  (Year)

I am:  ____ gay     _____ lesbian  ___ bisexual  ___ transgender ____queer

           ____ straight ally (supporter of LGBT community)

If LGBTQ,  Are you out and open in the community?  ___ yes    ___ no

Address: _____________________________________________________________________________

Permanent address (if Different):________________________________________________________

Phone:  (      )            _______     May we leave a message?   ___ yes  ___ no 

email:_________________________  

I hereby authorize the members of the PFLAG Scholarship Committee to review and discuss my grades and other records concerning me that are maintained by my school or are submitted by me for consideration.  This authorization is granted because I would like to be considered for a PFLAG scholarship.

Applicants Signature: ________________________________   Date: ___________________   
_________________________________________________________________________________

Question 1:  Name and location of school (s) you have applied to or have been accepted.

Do you have a major in mind? ______________________

Are you a graduating high school senior:  ____ yes   ____ no   

 Name of high school: ____________________    Date of graduation ______________________      

Are you in good academic standing?   _____ yes      ____ no          GPA:______________

Question 2:  What jobs have you had (including volunteer work), and what have you gained from these experiences?  If you had a leadership role please describe.

________________________________________________________________________________
Question 3:  What are your interests, hobbies, school clubs or extracurricular activities?  Choose one and tell us how it has affected your life.

____________________________________________________________________________________
Question 4: What would you like to be doing ten years from now:  How do you plan to achieve this?

_________________________________________________________________________________
Question 5:  What achievement or accomplishment has made you especially proud?

Question 6:  How has the fact that you are gay, lesbian, bisexual, transgender, queer, or a 
  straight ally affected your life?

_______________________________________________________________________________
Question 7: Is there anything else you would like to tell us?

______________________________________________________________________________
Permission to use image and other information

On occasion, PFLAG Lawrence/Topeka would like to use photographs, names and other information about scholarship recipients on our website or other places.  May we use your image and information for promotional purposes.  (Consent or non-consent will have no bearing on the decision to award you a scholarship.)

 Yes, PFLAG Lawrence/Topeka has my permission to use my image and information

  Yes, PFLAG Lawrence/Topeka has my permission to use my image and information, but they must contact me first with details about what specific information will be used and for what purpose.

   No, PFLAG Lawrence/Topeka may not use my image or information for promotional purposes.

REFERENCE 				Name of student_________________________________  

Have a person, 18 years or older, write letter of recommendation and mail to us by May 31st.  Must be from a teacher, minister, counselor, coach or employer.    The letter must include the following information:

Name

Address

E-mail

Phone

Relationship to student

How long have you known this student?

Is the student able to set goals and pursue them to completion?

What else to you think we should know about this student?

Send to:  Sonja Feist, PFLAG Scholarship Committee, 1910 SW Sieben Ct.  Topeka, Ks 66611 or email to: sffeist@msn.com   by May 31st