The Orphan Society of America

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OSA SCHOLARSHIP APPLICATION

• OSA scholarships are only available to U.S. residents.

Please complete and submit the form below to apply for an OSA scholarship. If you prefer to send your application by mail, please download the pdf version.

Name:
Mailing Address:
City:	State: Zip:
Home Phone:	Work Phone:
Email:

Do you consider yourself…
	African American Asian Caucasian Hispanic/Latino Native Hawaiian/Pacific Islander Other:

Gender:
	Male Female

Which of the following describes you best?...
	I am... An individual who has lost both parents to an act of violence, natural or man-made An individual who has lost one parent to an act of violence and is not currently in the custody of the living parent. An individual who has lost one parent to an act of violence and is currently in the custody of the living parent.

Are you presently in kinship care?
	Yes No
Relative:


Are you presently in foster care?
	Yes No
Foster parents:


Are you presently in a children's home?
	Yes No
Where?:


Do you have a legal guardian?
	Yes No
Who?:

How old were you when you were orphaned?

How old was your mom when she died?

How old was your dad when he died?

Who was your guardian when you were first orphaned?

Who is your guardian now?


Personal or Academic Reference:
Please submit two letters of recommendation.

Educational Information:

What is the highest level of schooling that you have completed?
	I am a high school senior. I am currently attending college. If attending college, what year?

High School or College attended or attending:
Name:
Mailing Address:
City:	State: Zip:
Phone:

Institution planning to apply this scholarship to:
Name:
Mailing Address:
City:	State: Zip:
Phone:
Major field of study:
Career objective

Verification of Acceptance -- Please submit a copy of your letter of acceptance to the program.

Financial Information:

Annual adjusted gross household income last year $

Please submit ONE of the following documents as proof of your household income:
1. A copy of your current federal income tax form OR 2. A copy of your social security award letter, VA benefits, pension statements or W-2forms, if you do not file a tax return
How many people live in your household (including yourself)?

Does anyone claim you on their tax return?	Yes No
(If yes, a copy of their tax form must be submitted with this application)

Statement of Purpose:

Please write a brief essay explaining your situation as an individual orphaned by violence and why you are seeking an OSA Scholarship.


Verification and Release:

I attest that the information I have provided is complete and accurate and I agree that The Orphan Society of America may verify this information. I agree that OSA may disclose information contained in this application to any donors who help fulfill my request. If The Orphan Society of America awards a scholarship to me, I hereby authorize OSA, on a royalty-free basis, to include my life-story as part of its publicity and fund-raising initiatives.


Signature:
Date: