Name *

First Name

Last Name

Program *

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HiSET

High School Diploma

Address *

Address 1

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Phone *

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Is this a cell phone? *

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Have you applied to this program? *

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Yes

No

By checking this box, I understand that the scholarship funds must be used within 5 years for eligible education expenses. I further understand that I may be asked to serve as a mentor or guest speaker at Wellspring for currently enrolled students. *

I agree to use scholarship funds within 5 years for eligible education expenses. I further understand that I may be asked to serve as a mentor or guest speaker at Wellspring for currently enrolled students.