Miss Southwest Michigan Scholarship Program
Office Fact Sheet

INSTRUCTIONS: The form must be COMPLETELY filled out to be considered for the Scholarship Program. Use only the space provided... NO ADDITIONAL SHEETS WILL BE ACCEPTED. After filling out the form, choose print from your browser window, sign and mail to Southwest Michigan Scholarship Program, P.O. Box 623, St. Joseph, Michigan 49085. If you have questions, please feel free to call the Executive Director, Frederic Zoschke at 269/428-4999

Full, Legal Name:  
Social Security Number:      Age:      Date of Birth:  
Home Address:  
City:       State:       Zip Code:  
Email Address:       Home Phone:  


School Address:  
City:       State:       Zip Code:  
County:       Phone:       Cell Phone:        


Parent(s)/Guardian(s) Name(s):  
Parents Address:  
City:       State:       Zip Code:   Phone:  
Father/Guardian Occupation:     
Mother/Guardian Occupation:  


ABOUT YOU:
Height:       Hair Color:       Eye Color:  
Do you have any brothers/sisters? What are their names & ages?
Were you born and raised in present community? If no, where?
Why did you decide to enter this program?
High School:       Date Graduated:  
College:       Years Attended:      
Degree Sought:       Class this coming September:      
Major:       Minor:      
Graduate School:       Degree Sought:      
Scholastic Honors:
Scholastic Ambition:
Career Ambition:
The Miss America Organization encourages the young women who participate in the program to become involved in their communities and to speak out on issues of concern to their community and the nation. If selected, the winner of this competition, what issue would you choose to focus on during your year of service? (Your "platform issue")
What type of talent will you present?
Special training in your talent?
Other Accomplishments?
Special training & Education (even if not in your talent field):
Hobbies:
Sports:
Ambitions for the Future:
Employment Experience:
Other interesting facts about yourself:
Complete name of other local or state pageant titles, and if you completed your year of service:
Name of the person who referred you OR how you heard about the program?
I certify that the foregoing information is true and correct to the best of my knowledge.
Contestant's Signature ____________________________________________ Date ___ / ___ /___
Parent/Guardian Signature ______________________________________________ Date ___ / ___ /___
Parent/Guardian Signature ______________________________________________ Date ___ / ___ /___
Parent/Guardian Signature ______________________________________________ Date ___ / ___ /___

CHOOSE PRINT FROM YOUR BROWSER MENU

Do not forget to include the following items... Copy of your Birth Certificate, Proof of Residency.