Scholarship Application

Record Type Name

Instructions:

Please fill out the form, attach the required documents (transcripts, a recent color photo, and legal guardian documentation if applicable), and click "Submit Form."

For detailed instructions and photo requirements, visit MedinaEC.org/Scholarships.

For questions, please email Scholarship@MedinaEC.org.

Please choose the scholarship for which you are applying. See scholarship details on the website.

*Scholarship Type:

Applicant Information

First Name:

Last Name:

Date of Birth:

Phone Number (include area code):

Email Address:

Mailing Address:

City:

State:

Zip Code:

School Information

Please list the school that you are currently attending (or previously attended if adult applicant) and the school that you plan to attend the following year.

minimum of 3.0

Current GPA:

Current School (previous if adult):

School Attending Following Year:

Parent/Guardian Information

Note: If the Applicant is a high school senior and not the Account Holder, contact information for at least one Parent or Legal Guardian is required. At least one parent's name should match the parent's name on the transcript and or Medina EC account.

Relationship to Applicant

Parent Name/Legal Guardian's Name

Relationship to Applicant

Parent Name/Legal Guardian's Name

Email Address:

Phone Number (include area code):

Account Information

Account Holder's Relationship to Applicant:

Note: If not self or parent, the Legal Guardian must submit appropriate documentation (see checklist below for file upload tool).

Enter your Medina Electric ACCOUNT #

Enter your Medina Electric MEMBER #

Account Holder's First Name

Account Holder's Last Name

Account Holder's Email

Account Holder's Phone

How did you hear about the scholarship program?

If "Other" is selected above, please indicate the source here

Other Source:

Documentation

Transcript: Prior to uploading your transcript, black out your Social Security Number. Many transcripts include your SSN, however it is not needed for Medina EC's scholarship verification.

Transcript

Photo: JPEG or PNG acceptable. Do not send photos of your drivers license.

Photo

If the applicant is not the child of the account holder, please provide documentation showing the relationship.

Legal Guardianship

Acknowledgement and Authorization

I understand that by signing this document or typing a digital signature that I am affirming that the information provided on this application is true and complete to the best of my knowledge. I understand and agree that any falsified information or significant omissions will disqualify me from further consideration for this scholarship and, if discovered after disbursement, will result in repayment of funds. I agree to authorize Medina EC to use my name and/or image for promotional purposes. I agree to permit the review of this application and my school records by anyone representing the Medina EC Scholarship program.

Type your full name as your digital signature

Applicant's Signature:

Required only if applicant is under 18. Type parent/guardian's full name as digital signature.

Parent/Guardian Authorization Signature (if applicant is under the age of 18):