Bruce Gilley Memorial Foundation Scholarship Application Personal Information Name (First, Middle, Last): Street Address: City: State: Zip: Email Address: Home Phone: Cell Phone: Date of Birth: Legal Guardian information if under 18 years of age Are you under 18 years old? YesNo If yes, please fill out the "legal guardian" section. Legal Gurardian (First, Middle, Last): City: State: Zip: Email Address: Home Phone: Cell Phone: Family Information Total family Size including yourself? Please list the name and ages of any dependents, or children 18 years of age and younger, and/or children or other relatives receiving support from your parent: What is your household income per year? Less than $14,999$15,000 - $29,000$30,000 - $44,999$45,000 - $59,999$60,000 - $74,000$75,000 - $89,000Over $90,000 Scholarship Details What event are you requesting funds for: Date of event: Total cost of event: Amount requested from the Bruce Gilley Memorial Scholarship: Additional Information: Have you applied for this Scholarship before? YesNo If yes when: Are you a previous recipient of this Scholarship? YesNo If yes when: How did you hear about the Bruce Gilley Memorial Scholarship? Church Information (if applicable) Are you or your family current members of a church, if so please name the church: What organizations within your church are you involved? Please provide the name, phone number, and email of a church leader for reference: Reference: Please provide the name of a non-family member and contact information: Full Name: Relationship to Applicant: Phone: Cell: Email: Personal Statement Please briefly share the reason for the scholarship request, detail of how the aide will be used and why you should be chosen to receive scholarship aide. Applicant: If given financial assistance would you be willing to submit in writing or email a brief description of your experience within two weeks after the event? Please share briefly with us any information, either personal or financial, that will help us respond wisely to your request. If awarded the scholarship. I authorize the Bruce Gilley Memorial Foundation to publicize my being a recipient. Signature of Applicant: Date: Signature of Parent/Guardian: Date: All information must be received 60 days prior to event for review and follow-up. Applicant Checklist A completely filled out application References and contact information Your Personal Statement If you prefer to submit a hard copy of the application please download here and submit to: Complete and submit to: Bruce Gilley Memorial Foundation P.O. Box 21 Lascassas, TN 37085 Please remember that all of the above checklist items must be included for the proper processing of your application. Also, please keep in mind that late or incomplete application will not be processed or considered.