Application Download Application The Yolanda Osby Memorial Scholarship
All questions must be answered fully and accurately. The information contained in this application will be kept confidential. Please submit the completed application to The Lionel and Cathlene Butler Foundation, 10026 Sagecourt Drive, Houston, Texas 77089, and request the high school to send an official transcript to the same address.
APPLICANT PERSONAL INFORMATION
Name _____________________________________________________________ Marital Status _________
Residential Address_________________________________________________________________________________ (No. and Street) (City) (State) (Zip Code)
Contact Information: Phone: ___________________ Email: _________________________________________
Age ______ Date of Birth _______________________ Place of Birth ____________________________ (Month, Date, Year) (City, State)
HOUSEHOLD FINANCIAL INFORMATION
Mother’s (Guardian’s) Name: _______________________________________________________________________
His/Her Employer _________________________________________ Annual Household Income ____________
Do you live in the same household as your parent or guardian named above ? Circle Yes or No. If the answer is 'No', please explain. ____________________________________________________________________________________________________________________________________________________________________________________________________________
What percent of your current support is being provided by your biological father ? _____________________
Total number of dependents claimed by your parent or guardian on the last federal tax filing ? __________
Please show below the full names, ages and current grade levels (including college) of dependents claimed by your head of household in the last federal income tax filing.
FULL NAME AGE GRADE
_______________________________________________________ _________ ___________
_______________________________________________________ _________ ___________
_______________________________________________________ _________ ___________
_______________________________________________________ _________ ___________
APPLICATION: (Continued, Page 2 of 3)
Please describe any unusual household financial problems or obligations you would like to share.
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please indicate below any employment you held during high school or college. Please indicate whether work was during the school session and whether in the evenings or on weekends, or during the summer.
Start End Employer Type of Work Mo. / Yr Mo. / Yr
_________ _________ _______________________________ ______________________
_________ _________ _______________________________ ______________________
_________ _________ _______________________________ ______________________
_________ _________ _______________________________ ______________________
HIGH SCHOOL EDUCATIONAL INFORMATION
Please have separately an official high school transcript or other document from your graduating high school submitted to the Fund attesting to your satisfactory completion. This information should include your grade point average (GPA) and/or your class ranking. In addition, please include the following information on this application below:
Your GPA (Example, 2.5 out of 4) _____________________________
Your class ranking. (Please check one ) Upper _________ Middle ________ Lower ____________
List below the three high school subjects you performed your best in.
First ______________________ Second________________________ Third _________________________
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OTHER ACTIVITIES-HIGH SCHOOL
Please list below the extracurricular school activities you have participated in such as band, athletics, drama, etc. Designate by each activity the grade in high school during which you participated. (For example: Band: all grades; Football: 11-12th grades)
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please list special honors and achievements you have received (honor societies, crafts, trades, skills, etc.)
______________________________________________________________________________________________________________________________________________________________________________ Please list your favorite recreation and hobbies. ______________________________________________________________________________________________________________________________________________________________________________
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COLLEGE ADMISSIONS INFORMATION
Please list the colleges you have applied to and indicate the current status of the application, i.e., pending or approved.
First Choice ______________________________________________________________________________________
Second Choice _______________________________________________________________________________________
Third Choice _______________________________________________________________________________________
For what career do you wish to prepare ? _____________________________________________________________
Please list any financial assistance you have applied for and indicate the current status, i.e., pending or approved (Examples of assistance: work/study, scholarships, grants, etc.).
Type of Assistance Name of School Amount
__________________________________ ____________________________________ _________
__________________________________ ____________________________________ _________
__________________________________ ____________________________________ _________
A Scholarship awarded by the YOMS will be a supplement to your college education. How do you plan to use these funds ?
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
REFERENCES
Please list the names, contact information, and addresses of three persons not related to you that the Foundation may contact as references, and ask these three references to write a letter of recommendation and forward to the Foundation. (This information may be emailed).
Name Contact Information (Phone, email) Position / Job Title
____________________________ ____________________________________ ______________________________________________ ____________________________________ __________________
____________________________ ____________________________________ __________________
ADDITIONAL REMARKS ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ I certify that to the best of my knowledge, all information contained in this application is true.
Signature _______________________________________________ Date _________________________