SCHOLARSHIP PACKET W.H.S. 2018-2019 Please check backside of application for additional questions or info.

One packet per student - You may receive one updated copy of your transcript - it will be your responsibility to obtain copies for distribution

SCHOLARSHIP DEADLINE ELIGIBILITY CRITERIA SUBMISSION 1. Common April 1 WHS General Guidance

Scholarship graduate includes Local

2. American Legion April 1 Local General Guidance Post 123

3. Mrs Bean's 5 April 1 WHS Former student of Mrs. Grade Alumni Beans of Ware Middle

4. Beaver Lake Club Local Ware or Beaver Lake Louis H Healy Jr Resident

5. Deslauriers May 1 Local General Mail Memorial 8

' ' Scholarship

6. Kobis, Don J. April 15 Local General Mail 7. Heather A Malin. April 1 WHS Athletic memorial award Mail

graduate 8. Marine Corps April 30 Local Patriotism Mail

League 9. Masonic Lodge April 1 WHS General Guidance

Scholarship graduate 10. Monson Savings April30 WHS General

Bank graduate 11. Moriarty, William E April 1 WHS General Mail

graduate 12. Moulton Insurance April 1 13. North Brookfield May2 WHS General Guidance

Savings graduate 14. Rotary Club of May 1 Local Demonstrate "service above Mail

Ware self' character -MUST TYPE

15. Seveney, PFC April 15 WHS General Guidance William F & graduate Richard Seveney ·,

16. Robert S.Slattery April 30 WHS Athlete, Leadership, Mail Memorial graduate sportsmanship & character

17. Veterans of Foreign April 1 Local General Wars

18. Ware Athletic Club April 1 Local Sports, extra-curricular Mail 19. Ware Knights of May 1 Local General

Columbus 183 20. Ware Lions April 15 Local Community Service Mail

21. Ware Masonic April 25 WHS General Mail Lodge graduate

22. Ware Police Union April 1 WHS Preference to pursuit of Mail graduate criminal justice field

23. Ware Republican April 30 WHS General Mail Committee Graduate

24. Ware Young Men's May 1 WHS General Mail Library Social Graduate Science Club

25. Ware Youth Fund May I ! WHS Academic, financial need Mail graduate and community service

WARE HIGH SCHOOL COMMON SCHOLARSHIP 2019

Name Date ------------------ --------- [?gr9[)l----_ UCClDlllQl ­

[gre[l_()CC]pl'lOI

Other family members currently enrolled in college

College you will attend:

What is your intended major or field of interest?

What is the estimated total cost of your education for one year?

Please include your activity profile sheet and complete the financial section on the back of this document

ANTIC/PA TED COMMON SCHOLARSHIP PARTICIPANTS

Cadet Corps Gosselin Monson Savings Bank North Brookfield Savings WHS= PTA M. Wojcik

Please CIRCLE yes or no to the following question:

Are either of your parents or grandparents veterans of the armed services? Yes NO

Have any of your family members been employed in the WPS system? No YES list building and job title

Employee Name: _

Relationship to applicant: _

Length of employment: _

DEADLINE: April 15= Financial need sheet must be included Please complete and return to guidance with your

transcript & activity sheet

Earle F. Howe

American Legion Post 123

Scholarship Application

Name ----------------------------- Phone -------------- Date of Birth ------------ Address -----------------------------

The American Legion Post 123 Scholarship is a History Scholarship. Applicants must write an essay on a topic chosen by the Post. The subject changes from year to year. This year the American Legion is celebrating its 100 Birthday. The essay you will be writing this year is on the History of the American Legion. Upon completion, your essay should be given to the school. They will select the top three essays and then forward them onto the Scholarship Committee at Post 123. The Committee will choose the recipient of the scholarship.

The recipient will be announced at graduation.

Mrs. Bean's 5° Grade Alumni Scholarship I believe that all my students have bright and promising futures. I can no longer help you within the walls of my classroom as you pursue your academic and career goals, but I would like to assist you with this scholarship as you begin your college career.

Class of 2019 Application

Application Criteria

1. Ware High grade 12 student

2. Former student of Mrs. Bean of Ware Middle School

3. Academic transcript and essay must accompany application

Application Deadline: April I

Amount of Scholarship: $150

Name: Date: ------------------ -----

Address: --~-~------~---~----~--- '[ 'elephone [Numb€I' .-

Institution you plan to attend as a college S[QCL' ­

Intended major of field of interest:

Extracurricular Activities: ----~~-------~......,__ _ Essay prompt: Explain how you have changed as a person/student since your time in our 5 grade classroom.

Optional: Attach a letter of reference

Please mail application to:

Mrs. Jennifer Bean

Ware Middle School

239 West Street

Ware, MA 01082

Beaver Lake Club Corporation Sponsored LOUIS H. HEALY JR. MEMORIAL

SCHOLARSHIP 2019 Application

This $1000.00 award is given in memory of Louis H. Healy Jr., who was a well-respected member of the Beaver Lake Club Community and the town of Ware. Applicant must be either a resident of the town of Ware or a child of a Beaver Lake Club member. They must be either a graduating high school senior, who will be attending an institution of higher education, or a currently enrolled college student. Applicants will be considered based on their academic excellence, community service, and demonstrated leadership. Please provide high school transcript and verification of enrollment when available. Application due April 12, 2019

Awards must be claimed by September 6, 2019.

Date -----------

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Address -------------------------

Town Phone Number -------------- -------

Email --------------------------

Attending as of Spring 2019:

High School_College

Institution you plan to attend as a student (Fall 2019)

School Activities ----------------------

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Please attach a brief essay describing what you hope to accomplish

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MICHAEL H. DESLAURIERS MUSIC SCHOLARSHIP

To Guidance Dept. Dune My [

The Ware Veterans Council will award the first annual Michael H. Deslauriers music scholarship to a graduating senior residing in Ware who plans to further his or her education in muslc. '

Michael was a devoted musician sharing his talents with the town of.Ware. He represented the town at the Quabbin Music Festival, Western District Festival and was a member of the Ware Community Band. A music graduate of Westfield State he continued to honor the veterans of the town by playing taps at their burial ceremony and also at all the Patriotic and Memorial events.

To apply for this award of $500, the student need only send their school transcript and an essay application stating their music accomplishments and what their future music plans are.

Please mail to: Ware Veterans Council CIO Richard Rucki 8 First Ave. Ware, MA 01082

Thank you,

Richard Rucki Chairman of the scholarship committee

DON J. KOBIS SCHOLARSHIP

Criteria:

1. Ware High School grade 12 student 2. Scholarship must be used in an accredited institution of higher learning 3. Transcript must accompany application

Application Deadline: April 15

Amount of Scholarship: $200

Name: Date: ------------------ ------ Address: Telephone: Father's Name: Occupation: Mother's Name: Occupation: ----- School you will attend: ------------------- Field of study: ----------------------- Acceptance confirmed: Yes No (please circle)

List any aid or assistance you have received so far:

State estimated cost of your education for one year _

List any family member currently attending college and which schools ------------------------------

TWO CHARACTER REFERENCES: Give name and address (l) _ (2) _

List extra curricular/civic activities

Mail application to: Mrs. Claire Kobis 22 Old Poor Farm Road Ware, MA 01082

Heather A. Malin Scholarship

Congratulations on your achievement, and I wish you all the best as you continue your academic career. I knew you could do it !!

Application Criteria:

• Former student of Mrs. Malin's 3" grade class at SMK • Grade 12 student graduating from Ware High School attending college in the fall • Application accompanied by the writing prompt and a transcript

Application Deadline: April 1 Amount: $100

Application:

[]A[[[( - Jl[h[ --- Address: _

School you will be attending.'' '' [is r

Intended major or field of study: _

Extracurricular Activities: _

I offer this scholarship as a way of saying thank you for leaving me with lasting memories and sharing my classroom with me. I also graduated from Ware High School and had many great teachers in the Ware Public Schools. I remember them all. I only hope I have been able to leave you with lasting memories.

What is one of your memories from third grade? (Use another sheet if preferred) _

Prompt: On a separate piece of paper, tell me about an academic achievement from any grade that you I ' are most proud of and why. ·

Please mail the application to or drop it off at;

Mrs. Heather Malin Stanley M. Koziol Elementary School 4 Gould Road Ware, MA 01082

Marine Corps League

Scholarship Application 2019

Name._ Social Security; ­

Address --------------- Male __ Female __

Phone# --- , City State Zip

Hjqh School­ College accepted to _

Graduation Date: ------- Tuition Cost: ·-------

How do you plan to pay for your education? Parents Earnings Loans __ Scholarships (check all that apply) School is: 4yr College/University __ 2yr College Technical School ----- 1 will live: On Campus Off Campus At Home­ ([[Q(IQ [[Q[­ ([QP (j(Q[6, Please list (mandatory) the name of a family member who has served in the United States Marine Corps or as a Navy Corpsman (Medic) with a Marine Unit for more than 90 days. This includes living or deceased or "step-members" ie. step-father, brother,etc.

Special friend or personal circumstances to be considered by the scholarship committee:

(use additional sheet if needed)

School Activities: (use additional sheet if needed) _

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Date Received: _ Work History: _

Masonic Lodge Scholarship

Criteria: Graduate who resides in the Town of Ware

Application Deadline: April 1st

Amount of Scholarship: $250

Mail to: Masonic Lodge Scholarship Committee: C/O Edan Lodge Brad Dimiero PO Box 22 Ware, MA 01082

Name: Date: ----------------------- --------- Address: Telephone: ----- Parents Name: ------------------------ Essay stating your future plans and community services you have been involved in:

Please continue on the other side if necessary.

Please include a transcript with this application

Monson Savings Banks

Scholarship Application

Name of Scholarship:

PLEASE FILL THIS FORM OUT COMPLETELY, ACCURATELY AND NEATLY-TYPE OR USE BLACK INK. PLEASE INCLUDE A TRANSCRIPT

Full Name:-------------------------------------

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A/hat Career do you want to pursue after you finish college?

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]>F (College of Choice' Znd College Of (Choice. 3'° (College of Choice.

Tuition: ------------- Tuition: ------------- Tuition: -------------

List all scholarships, grants and financial aid which you have been awarded:

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[)Q \/OU OW 3 (3r?' Will you commute to College?

WILLIAM E. MORIARTY SCHOLARSHIP Application

Criteria: Ware High School (WHS) graduate, college bound senior who demonstrates academic achievement (GPA 3.0 or higher- transcript required) and at a minimum, 25 hours of documented service to the community

Award; A certificate of award at graduation. You must submit 1 semester grades and proof of 29 semester enrollment to cpetraware@aol.com or WEM, P.O. Box 793, Ware, MA 01082 to receive the monetary scholarship award.

Name: ---------------------- Date: -------- Address: --------------------------------- Parents/Guardian: ----------------------------- Other family members currently enrolled in college: _

Colleges/schools you have been accepted to or have decided to attend: _

What is your intended major or field of interest? _

List activities you have participated in (or Activity Sheet if completed) while attending WHS:

Honor, scholarships, awards received while at Ware High School: _

**Community Service distinguishes you as a W.E. Moriarty Scholarship applicant by showing your commitment to making the world a better place. Please provide a short essay describing your efforts and activities in helping those in your community.

Requirements & Deadline: Must submit transcript, completed application, community service verification, and short essay to WHS Guidance no later than April 1. Incomplete applications will not be considered.

Scholarship Application

Moulton Insurance Agency, Inc. 143 West Street, P.O. Box 90

Ware, MA 01082

NAME: _

ADDRESS: ---------------------

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SCHOOL ACT[/IT[ES

COMMUNITY SERVICE ACTIVITIES:

COLLEGES YOU HAVE BEEN ACCEPTED AT:

MAJOR YOU ARE CONSIDERING:

ARE YOU OR YOUR FAMILY MEMBERS INSURED WITH OUR AGENCY? IF SO, NAMES PLEASE (Not a prerequisite): _

Additional Requirements - Brief essay on your future goals Transcript of your grades

Application must be returned by April 14, 2019

NORTH BROOKFIELD SAVINGS BANK SCHOLARSHIP APPLICATION

2018--2019 Due to Guidance Department May 2

ADDRESS:

COMMUNITY SERVICE ACTIVITIES:­

COLLEGE YOU PLAN TO ATTEND:

ANTICIPATED EDUCATIONAL COST FOR ONE YEARS­

EXPLAIN WTHY YOU WANT TO CONTINUE YOUR EDUCATION:

• ROTARY CLUB OF WARE, INC,

P.O. Box 177 Ware, MA 01082

Ware Rotary Scholarship

Each year the Ware Rotary Club offers scholarships of $500.00 to up to three graduating seniors who reside in Ware. They must meet certain criteria consistent with the goals and purpose of Rotary.

The criteria requires that the student

• Be in good standing throughout his or her high school career • Demonstrate "Service Above Self" through his or her actions and involvements in school

and community • Exhibit "character" through his or her interaction with fellow students and community

members • Must be furthering his or her education at an institution of higher education in the fall

of the graduating year.

The Rotary Scholarship Application Procedure is as follows:

• A one page typewritten letter written by the applicant indicating how he or she has fulfilled the above criteria

• A high school transcript which includes the overall grade average • The school which the student will be attending • One letter of recommendation from a teacher or advisor

Please submit by May 1° to: Kathy Deschamps, Scholarship Chairperson

Rotary Club of Ware

PO Box 177

Ware, MA 01082

Awards will be made at graduation and the recipients will be invited to a Rotary meeting to receive the monetary award.

Any questions may be addressed by calling Kathy Deschamps 413-967-5187

Seveney Scholarship In memory of brothers PFC William F.and Richard Seveney

Criteria: Scholarship must be used in an accredited institution of higher learning. The Seveney Scholarship seeks to recognize future Ware High School graduates who are dedicated to the community. The Scholarship fund actively seeks high school seniors who exhibit leadership, community involvement, exemplary character and high academic standards. Students must compose a compelling essay outlining their personal achievements and career goals.

Transcript must accompany application

Application Deadline: April 15

Amount of Scholarship: 2- $100

Mail to: Elaine Seveney 5 Sunny Hill Drive, Ware, MA 01082

Name: Date: ---------------------- -------- Address: Telephone: Parents Name: Number & ages of Brothers: _ Number & ages of sisters:

School you will attend: _ Field of study: Acceptance confirmed: Yes No (please circle)

List any aid or assistance you have received so far:

State estimated cost of your education for one year

List any sibling currently attending college and where _

continued

Robert Scott Slattery Memorial Scholarship Application Deadline: May 3, 2019

Eligibility

1) Shows personal integrity, good character 2) Athlete at Ware Jr/Sr High School 3) Plans to further his/her education (i.e. 4-year college, community college, technical school)

Description of Scholarship

The recipient of this scholarship will have been impacted by the life lessons gained through athletics. They will have shown leadership, sportsmanship, and character on and off the athletic field.

Application Requirements:

Completed Application Cover Sheet Copy of Official Transcript Personal essay that answers the following questions:

o What does athletics mean to you? o How has your athletic experience influenced your character?

Essay may be written or done in video form Letter of recommendation from an academic teacher or athletic coach speaking to your character

Please email your application to robertscottslatteryscholarship@gmail.com or mail to Joanna McNeill 24 Westview Drive

Belchertown, MA 01007

Important: The Robert Scott Slattery Memorial Scholarship will be awarded to the recipient/s contingent on submission of first semester grades from an educational institution. If the scholarship is not claimed within one year, the scholarship will be forfeited.

Robert Scott Slattery Memorial Scholarship

Information Cover Sheet

Applicant Information

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Year of Graduation: -------

Gender: ------

[\/[)[[[[)Q A(]([[($S

Street Address/PO Box City State Zip code

Email address: ----------------------------------

Phone II: ----------

Parent Contact Information

Name: ------------------- [Oh(yp\Q [F'

High School Athletic Career

Sport # of Seasons Level (Varsity/JV) Leadership Roles (i.e. captain)

Education Plans

School: _ Fjeld of Study'

Please email your application to robertscottslatteryscholarship@gmail.com or mail to Joanna McNeill 24 Westview Drive

Belchertown, MA 01007 Be sure to include the following:

Information Cover Sheet Official Transcript Personal Essay Letter of Recommendation

Veterans of Foreign Wars SCHOLARSHIP

Return to Guidance Department

[]A[[) Jd(--

Address _

Parents/Guardian: _

List community service activities that you have participated in:

List school extra curricular activities that you have participated in:

Active parent/guardian/grandparent of VFW Post 2577 NAME _

Inactive parent/guardian/grandparent of VFW Post 2577 NAME _

MUST INCLUDE:

A copy of your school transcript is required.

A copy of your school student profile is required.

DEADLINE FOR APPLICATIONS: April 1th

REV. 3/29/16

Ware Athletic Club Scholarship

Any student graduating from Ware High School, or a son or daughter of a member in good standing graduating from any other high school, may apply for the Ware Athletic Club Scholarship.

Basis for selection will be that the recipient is a worthy high school senior who has demonstrated good school citizenship and whose achievement level is equal to his/her ability scholastically .

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Application Information

Name: ----------- Address: ----------

Age: ­

Town: -----

Date of Birth: --------

Tel. # --------- High School graduating from: Date of graduation:

Father's name:------.. Occupation'­ Mother's name: Occupation: Number of children in family under 18: ----- Other family members in college and where they attend: /hat college do you plan to attend'?-------­ \/hat is your intended major?_------­ Have you been accepted? Anticipated date of enrollment'?

List any extra-curricular activities that you participated in during high school: _

NOTE; Statement of future and educational goas as well as any individual additional information which you may wish to add that may help the Executive Board evaluate your application will be helpful and appreciated. Use reverse side of this application or feel free to attach an additional sheet.

····················································~~-···································· To be considered for the Ware Athletic Club Scholarship:

1. Complete this application in its entirety 2. Attach transcript of grades and class rank 3. Application must be post marked on or before April 1'. Applications postmarked after this date will

be discarded. Applications should be mailed to: Ware Athletic Club Scholarship Committee

P.O. Box 303 Ware, MA 01082

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Ware Knights of Columbus Council #183 Scholarship Application • { t% 4 »4 ,

j. Name: .Age:._· __

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ligh School Attended: Ware Jr-Sr High School

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'choolis a: 4 year college/university will live: On campus

2yr college

Off Campus

Technical School home with parents

flow do you plan to pay for your education? Check all that apply:

Parents Earnings Loans Scholarships

lave you or anyone of your family ever been a member of the Knights of Columbus?

please list: -'-------

' pecial family or personal circumstances to be considered by schplarship 5 ·'; mmittee: '

3chool Activities: List or rnclude _

f]rt@gr \\/grk; [O/UT Q] par[IC]Dal[OT- -­

]onors received & year

\/ork History: _

forts/extracurricular: :·-- _

'am munity or church activities:

1. Include Transcript/gpaandSATscores ,+\.wl±2\y4:.. 2. Please include a statement why you should be awarded the Knights of_Columbus Council #183 on the reverse

side.

:ertify all Information on this form is true and complete to the best of my knowledge. I may be asked to provide proof 'this information.

udent signature Date:

rents signature; Date: , ail_to:_ Knights of Columbus Scholarship, 126 W. Main Street, Ware, MA 01082 by May 1.

WARE LIONS CLUB/EMIL ST. ONGE SCHOLARSHIP APPLICATION

Open to any Ware resident graduating in upcoming year

NAME: _

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Please supply school transcript, involvement in community, future plans, and

any reference letters, by May 1st to:

WARE LIONS CLUB SCHOLARSHIP

PO BOX 913

WARE, MA. 01082

WARE POLICE UNION SCHOLARSHIP APPLICATION

Criteria for submitting this application: 1. You must be a grade 12 student attending Ware High School 2. This scholarship must be used at an accredited institution of higher learning, which awards a

certificate upon completion of the accredited courses 3. A school transcript must accompany this application 4. At least two (2) letters of character reference must accompany this application 5. Preference MAY be given to applicants who will be pursuing their higher education in the field of

Criminal Justice 6. Application deadline: April 1 7. Scholarship amount: $500 8. If awarded, this scholarship shall be paid upon proof of acceptance to an accredited institution and

after the completion of the first semester of classes with passing grades

Name:-------------------

Address:

[/[[her' []A[Tr------

Father's Name:

Total Number of persons in your household:

College you plan to attend:

Field of study:

Date:

Phone#

Occupation:

Occupation:

Is your acceptance confirmed?

State your estimated cost of education per year: _

Do you have any other family members attending college?

List any financial aid or assistance you have or may receive:

List any extra curricular and or civic activities:

Mail this completed application to: President, Ware Police Union 22 North Street Ware, MA 01082

WARE REPUBLICAN TOWN COMMITTEE SCHOLARSHIP

Criteria: If 18, must be a registered voter. Essay: What the constitution means to me. Include Copy of Transcript

Scholarship amount: $500

Include list of all Activities, Award or Honor, Leadership Positions, Community Service, Volunteer Work, Work Experience:

Application Deadline: Post marked by April 30 Mail applications to: Ware RTC

P.O. Box 553 Ware, MA 01082

Social Science Club of Ware/Young Men's Library Association Scholarship

Each year, the Social Science Club of Ware/Young Men's Library Association offers scholarships to one or more graduating seniors who are residents of the Town of Ware, attend any area high school, and meet certain criteria.

Criteria

0 The student must be in good standing throughout his/her high school career. o The student must be involved in school and community activities. e The student must be furthering his/her education at an institution of higher

education in the fall of the graduating year.

The Social Science Club of Ware/Young Men's Library Association Scholarship Application Procedure is as follows:

1. A properly typed, formatted, one-page letter, indicating how he or she has fulfilled the scholarship criteria, is to be written and signed by the applicant, and submitted, along with information requested below.

2. High School transcript (unofficial) showing overall grade-point average.

3. Student Activity sheet.

4. College or university applicant has been accepted at (applied to and/or hasn't made a decision) and starting date. ..

5. One letter of recommendation from a teacher or advisor.

6. If applicable, employment and/or special financial circumstances (i.e., brother/sister in college, family illness, etc.).

The Scholarship Committee Social Science Club of Ware/'Young Men's Library Association

3 7 Main Street Ware, MA 01082

Due Date: May 1

The scholarship award will be made at Graduation, and the monetary award will be given after successful completion of the first semester. A transcript of the recipients' grades must be submitted in order for him or her to receive the award.

WARE YOUTH FUND SCHOLARSHIP Criteria: Ware High School graduate who demonstrates academic achievement, need and

service to the community Award: will be presented prior to the second semester of college.

Name Date ------------------- ----------

Address -----------------------------

Parents/Guardian & Occupations

Other family members and note currently enrolled in college _

Colleges/schools you have been accepted to or have decided to attend:

What is your intended major or field of interest?

List activities, hobbies, community service you have participated in

Other information you feel is pertinent _

DEADLINE FOR APPLICATIONS : May 1, 2018

Transcript required Mail application to: Chantel Bleau I Ware Youth Scholarship Fund IP. 0. Box 812, Ware, MA 01082

Wing Memorial Hospital Auxiliary, Inc. 2019 Scholarship Application

Check school: [] Palmer D Monson [] Ludlow D Belchertown [] Minnechaug D Pathfinder [] Ware

Applicant: Mailing Address:

Tel.#:

C II olleges/Universities you ave een noti ie 0 acceptance - ist in order ot your choice: College/University Estimated Annual Cost

1. 2. 3.

I h b f d f Ii d f

Please provide the following information:

1. What medical field/profession are your committing to:

2. List three goals you aspire to achieve related to the medical field/medical profession you have chosen:

a.

b.

C.

3. Why do you feel you deserve to be awarded this scholarship? (100 words or less)

Wing Memorial Hospital Auxiliary, Inc. 2019 Scholarship Application

Applicant:

ACTIVITIES SHEET

Volunteer/Community Service - Medical related 9 10 11 12

Volunteer/Community Service - Other 9 10 11 12

Awards 9 10 11 12

Club/Group Activities/Sports 9 10 11 12

Check Applicable School Year

4. List any work experience: Employer Position/Job Dates of Employment

Wing Memorial Hospital Auxiliary, Inc. 2019 Scholarship Application

Applicant:

Please enclose the following with your application submission. Any incomplete or missing information will automatically disqualify the application.

D This Application

[] Transcript (obtain from Guidance Department)

L] Two letters of recommendation (not from a relative) [] small photograph (passport size preferred) O [] Must be mailed and postmarked by March 31, 2018' to:

Teresa Grove - Development Office Attn: Auxiliary Scholarship Applications Baystate Wing Hospital 40 Wright St. Palmer, MA 01069-1138

OR o

Email the complete package to teresa.grove@baystatehealth.org by March 31, 201,8

If chosen as a scholarship recipient, I give permission to Wing Memorial Hospital Auxiliary, Incorporated to use my photograph for publication.

Applicant's Signature: _

If Applicant is under 18 years of age, a parent or legal guardian must sign below:

By signing above, I certify I am the parent or legal guardian of the Applicant named above, and if this Applicant is a chosen recipient, I hereby give my permission to use the photograph provided for Auxiliary Scholarship publication purposes.

Attach photograph here

Wing Memorial Hospital Auxiliary, Incorporated does not discriminate based on race, color, sex, religion, national origin, sexual orientation, or disability.