Scholarship Application Please complete and submit this form by clicking on the "Submit Form" button below. Please attach your transcript, a recent color photo, and, if necessary, legal guardian documentation using the document upload tool at the end of the form. Detailed application instructions and requirements can be found on the website at www.medinaec.org/scholarships. If you have any questions please visit MedinaEC.org, email Scholarship@MedinaEC.org or call 1-866-632-3532. Fields with * are required fields. Scholarship Type Please choose the scholarship for which you are applying. See scholarship details on the website. *Scholarship: High School Senior Adult less than 25 yrs old Adult 25-63 years old Applicant Information *First Name: *Last Name: *Date of Birth: (MM/DD/YYYY) *Phone Number (include area code): *Email Address: *Mailing Address: *City: *State: *Zip Code: *Current GPA: Please list the school that you are currently attending (or previously attended if adult applicant) and the school that you plan to attend the following year. *Current School (previous if adult): *School Attending Following Year: How did you or your parents hear about the scholarship program? (check all that apply) TX Co-op Power School E-newsletter Website Social Media Other If "Other" is selected, please indicate source Other Source: Account Information *Medina EC Member Number(s): *Name on Account (on latest bill): *Account Holder's Relationship to Applicant: Self Parent Legal Guardian If not self or parent, the Legal Guardian must submit appropriate documentation (see checklist below for file upload tool). *If the Applicant is a high school senior and not the Account Holder, the information below is required for at least one parent/legal guardian. Legal Guardian/Mother's Name: Phone Number (include area code): Email Address: Legal Guardian/Father's Name: Phone Number (include area code): Email Address: Documentation Upload Transcript: Prior to uploading your transcript, black out your Social Security Number. Many transcripts include your SSN, however it is not needed for Medina EC's scholarship verification. *Upload your transcript: Photo: JPEG or PNG acceptable *Upload your photo: Legal Guardian: Upload documentation if applicable Upload Legal Guardian documentation: Acknowledgement and Authorization I understand that by signing this document or typing a digital signature that I am affirming that the information provided on this application is true and complete to the best of my knowledge. I understand and agree that any falsified information or significant omissions will disqualify me from further consideration for this scholarship and, if discovered after disbursement, will result in repayment of funds. I agree to authorize Medina EC to use my name and/or image for promotional purposes. I agree to permit the review of this application and my school records by anyone representing the Medina EC Scholarship program. Click here to draw your signature. Applicant's Signature With your mouse, draw your signature. Then click Finish. Date: Click here to draw your signature. Parent/Guardian Authorization Signature With your mouse, draw your signature. Then click Finish. (if applicant is under the age of 18) Date:
