ALAS Scholarship Application - ALAS | Always Learn and Survive

Student Information

Name(Required)

First Last

Age(Required)

Address(Required)

City(Required)

State(Required)

Zip Code(Required)

Home Phone

Cell Phone

School(Required)

Birth Date(Required)

Email(Required)

Is your teen on Facebook?(Required)

Yes

No

Parent Information

Mother's Name(Required)

Father's Name(Required)

Do both parents live at home?(Required)

Yes

No

Address (if different from teens or non-primary parent)

City

State

Zip Code

Mom's Cell Phone(Required)

Dad's Cell Phone(Required)

Mom's Email

Dad's Email

Are you on Facebook?(Required)

Yes

No

Is there anything we should know about the student’s current or past circumstances that you would like for us to know?(Required)

Does the student have a substance abuse history?(Required)

If yes, please provide details

Does the student have criminal history?(Required)

If yes, please provide details

Supplemental Information

Household Annual Income(Required)

0 - $25,000

$25,000 - $50,000

$50,000 - $100,000

$100,000 +

What language is primarily spoken at home?(Required)

What is the student’s primary language?(Required)

What obstacles is the student facing that may delay him or her from becoming a leader in his/her life?(Required)

What are the student’s strengths?(Required)

What are the student’s weaknesses?(Required)

Who does the student look up to, and why?(Required)

In a few sentences, tell us why you are interested in ALAS, Always Learn And Survive Youth Program?(Required)

Will the student be available for interview as a part of the scholarship application?

Yes

No