Registration

Name

Email Address

Phone Number

Street Address

City

State

Zip Code

Country

Parent/Guardian Phone Number

High School Name & Address

Grade

Counselor

GPA (must be 3.0 or higher)

Date of Prom

Dress Size (for gown if chosen)

Extra Curricular Activities

Tell us about you.

What are your plans for the future?

Why is this scholarship needed?

1. Referral Name/Number

2. Referral Name/Number

Submit your essay: At least 750 words. Can be pasted here or emailed to Kissktore@gmail.com