Granting dreams to children who are critically or chronically ill

Larry Moore Scholarship Application

Name

First Name

Last Name

BIrthday

YYYY

SSN

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Name of Institution you plan to attend

Cost Per Year

Field of Study

Have you made an application?

Yes

Have you been accepted?

Yes

Cumulative GPA

ACT or SAT Composite Score

While attending classes, where will you be living?

At home

On campus

Total number in household

Parent Marital Status

Occupation of Father

Occupation of Mother

List your school involvement for grades 9‐12 or currently in college:

Are there any unusual circumstances that would clarify greater need in this scholarship? If so, please explain

Please use the space below and complete a 300-word essay on “What the Dream Factory Means to Me”