Cultural Crossroads, Inc.
The Cultural Crossroads scholarship ($500.00) is available to all senior high school students in
Jackson County, Missouri, who are enrolled or about to be enrolled in a public institution of higher
education (i.e., a state or county university or community college, but not a for-profit institution) in a
degree or vocational program, and who demonstrate an awareness of cultural competency and a
desire to promote peace and justice.
The application form follows. Please fill it out completely and submit to Cultural Crossroads.
Remember that there are no incorrect answers – we simply want to learn about you and your plans.
We wish you good fortune, both with this application and with your future plans.
Application deadline is February 1. Application may be submitted in several formats:
For online form, click here: https://form.jotform.com/92106260789158
In the alternative, you may print the following form and submit it by email or mail to:
o
By email to CulturalCrossroads@hotmail.com
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By mail to Cultural Crossroads, Inc.
3605 Blue Ridge Blvd
Independence, MO 64052
APPLICATION FOR CULTURAL CROSSROADS SCHOLARSHIP
A.
PERSONAL INFORMATION
Name:
___________________________________________________________________________
Address:
___________________________________________________________________________
___________________________________________________________________________
Email address:
___________________________________________________________________________
Phone number:
___________________________________________________________________________
Age at last birthday: _____________
(DOB: MM/DD/YYYY): ____/____/________
High school:
___________________________________________________________________________
Higher education institution:
___________________________________________________________________________
___________________________________________________________________________
I am enrolled for next fall.
I am not enrolled yet, but will be by this date: ________________________
Degree or program of interest:
__________________________________________________________________________
IF STUDENT IS UNDER THE AGE OF 18 YEARS:
Parent/Guardian Name(s)
_____________________________________________________________________
Parent/Guardian Contact number __________________________________
Parent/Guardian Email: _________________________________________________
HIGH SCHOOL INFORMATION (please attach copy of your “unofficial” transcript)
Attendance record: if less than perfect, please tell us what issues you faced:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Grade point average: __________
Honors received in high school, if any:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Extra-curricular activities in high school, if any:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
COMMUNITY SERVICE/VOLUNTEERISM:
Does your school offer community service opportunities?
YES (answer next two questions)
NO (skip next two questions)
How many hours of service did you perform last year? ________________________
How many hours during previous years? ____________________________________
Have you volunteered with any nonprofit organizations? YES NO
If so, which ones and for approximately how many hours?
___________________________________________________________________________
___________________________________________________________________________
In addition to community service organizations, I have been involved in the following
clubs, both affiliated with my high school and nonaffiliated, in my free time:
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
SOCIAL QUESTIONS
What do you think is the most important benefit from your high school years?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What do you hope to achieve by enrolling in higher education (i.e., past high school)?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
What do you think is the greatest challenge facing our society at this time?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
How would you address that challenge?
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
EXTRA CREDIT: In 200 words or less, describe your “ideal” society and how you
believe you can make a difference in the world to realize that ideal. (Attach an extra
sheet for this question.)
If you choose to not include an “extra credit” essay, mark here _____ and simply
sign and complete your application.)
REQUIRED SIGNATURE(S):
I confirm that the information provided on the application is true and correct, and I
understand that including any knowingly false information automatically disqualifies
me from eligibility. If I earn the scholarship for which I am submitting this application,
I give permission for my name and photo to be used in publications.
Student Signature:
_____________________________________________________________________________
IF STUDENT IS UNDER THE AGE OF 18 YEARS:
Parent/Guardian Signature: ______________________________________________________
