APPLICATION FOR

LKCC SELF-RELIANCE AWARD

Administered by Lower Keys 
Chamber of Commerce

The Self Reliance Award Program is initiated to provide cash awards for the High School Seniors in Monroe County Schools (Marathon HS, Key West HS, and Collegiate Academy) who best exhibit this fine character trait. Acknowledging that the outstanding scholar and athlete are often rewarded with college scholarships, the Self Reliance Award is designated to seek out and honor the Senior who “does the best with what he or she has” whether he or she is a scholar, an athlete, a student leader or youth who must seek employment to help his or her family meet expenses.  Applicants must reside within the boundaries of the Lower Keys Chamber of Commerce (the west end of the Seven Mile Bridge through Stock Island).  

The following statements are correct and true to the best of my knowledge and belief.

Applicant’s Signature:  	

Date:   	

Name: 	
First	Middle	Last

Address:  	
Street	City	State

Telephone Number:  	

Male	Female

PARENTS AND FAMILY
Father’s Name: 	 Address: 	
Street	City	State
Mother’s Name: 	 Address (if different than Father’s): 	
Street	City	State

If you do not live with your parents, complete the following:
Guardian’s Name: 	 Guardian’s Address: 	
Street	City	State

I live with Guardians because: 	_____________________________________________

__________________________________________________________________________

www.lowerkeyschamber.com
Applications must be submitted by May 1st to Lower Keys Chamber of Commerce Scholarship
        31020 Overseas Highway, MM 31, (PO Box 430511) Big Pine Key, Florida  33043

SCHOOL ACTIVITIES

List all activities, clubs or organizations you are in at your school, such as athletics, service clubs academic clubs, etc., since leaving the ninth grade.

Sophomore Year (School Attended:	)	Office or Duty	

		

		

Junior Year (School Attended:	)	Office or Duty	

		

		

Senior Year (School Attended:	)	Office or Duty	

		

		

COMMUNITY ACTIVITIES

List all activities, clubs or organizations you are in other than school, such as Church involvement, Boy Scouts, Girl Scouts, Red Cross, Charity Drives, etc., since leaving the ninth grade.

Sophomore Year	Office or Duty	

		

		

Junior Year	Office or Duty	

		

		

Senior Year	Office or Duty	

		

		

PLANS FOR FUTURE

State your goals and objectives upon completion of High School:

EMPLOYMENT HISTORY
List all jobs whether part time or full time for which you have received pay. For example, this could include mowing lawns, delivering papers, baby-sitting, waiter/waitress, sales clerk, etc. Begin with your present or most recent job and then continue listing in order all jobs held back to end of ninth grade.

Employer and
Name of Supervisor	
Phone
Number	
Type of Work	Hours Per Week	Dates Worked	
				    Start 		End 		

						

						

REFERENCES

Please list the names of a direct supervisor, teacher and a personal reference, not a relative, to whom we can send rating forms. (Be sure to advise reference you have listed them on this application)

Employer (Direct Supervisor):

Name:                                                                                                                          
First	Last

Address:                                                                                                                        

Street

Telephone Number: 	

City	State

Email: 	

Teacher:

Name: 	
First	Last

Address:  	

Street

Telephone Number:  	

City	State

Email: 	

Personal Reference:

Name: 	
First	Last

Address:  	

Street

City	State

Telephone Number: 	

Email: 	

PERSONAL ESSAY

In 300 words or less, define what "Self Reliance" means to you and give specific examples of how you have been self reliant  in any aspect of your life.