Application #: ___________(please leave blank)

2010 DIPSEA RACE FOUNDATION SCHOLARSHIP

OFFICIAL APPLICATION FORM

Student Name ___________________________________________________

Last First Middle Initial

Address: ___________________________________________________

Number & Street

___________________________________________________

City Zip Code

________________________ _________________________

Student’s Home Telephone # Student’s Social Security #

___________________________________________________

Student’s E-mail Address

___________________________________________________

Contact E-mail Address

Name of Parent

or Guardian: ___________________________________________________

Student’s School: ___________________________________________________

School Principal: ___________________________________________________ Name Telephone #

Team Head Coach: ___________________________________________________ Name Telephone #

Student’s

Participation: ___________________________________________________ ___________________________________________________

List position on team(s) (i.e., 200 meter runner, triple jump specialist, volunteer,

Equipment manager, etc.) List events participated in and placing, times, including

Awards. Attach as an exhibit to this application if necessary.

__________________________________________________________________________________

This Section is For Official Use Only

Date Received: _____________________ Received by:________________

(School.cov)

__________________________________________________________________________________

SCHOLARSHIP APPLICANT QUESTIONNAIRE AND VERIFICATION

(Answer Yes or No to the Following Questions)

1. Are you a citizen of the United States of America? __________________

2. Are you an active participant in your school’s cross country or track & field team? _____

3. Are you in the 2010 graduating class of your school? _______________

4. Which college will you attend in the fall of 2010? ____________________________________

5. Have you ever officially entered and finished, or volunteered in an Annual Dipsea Race? __________ If yes, what year did you participate? _____________

I verify that I alone prepared my year 2010 Dipsea Foundation Scholarship Application, and all information submitted with my application is true, accurate and complete to the best of my knowledge and belief and agree that the Dipsea Foundation may release or publish the application content, except parents’ financial information:

Date: _________________________ ____________________________________

Student Signature

Parent or Guardian’s Verification

I verify that I am the parent or guardian of the above signed applicant and I confirm that my child or ward has completed the attached application solely with his or hers own skills and efforts, and the information submitted with the application is true, accurate and complete to the best of my knowledge and belief. I also agree that the Dipsea Foundation may release or publish the application content, except parents’ financial information:

Date: _________________________ ______________________________________

Parent or Guardian Signature

______________________________________

Type or Print Name of Parent or Guardian

School Official’s Verification

I verify that I am the school official at the high school where the student applicant attends and that the official school records and transcripts attached to this application is true, accurate and complete to the best of my knowledge and belief. I further verify that the applicant is in the graduating class of 2010.

Date: _________________________ _____________________________________

School Official’s Signature

______________________________ _____________________________________

Title Type or Print Name of School Official

(School.cov)

How To Complete Scholarship Application

In addition to the official application form, students seeking a Dipsea Race Foundation scholarship should provide the following items:

1- School transcripts of scholastic record;

2- Evidence of community leadership or participation in volunteer activities;

3- An essay that reveals some aspect of your personal relationship with the Dipsea Race

and/or trail;

4- Explanation of your financial need for a scholarship;

5- Athletic records of your sports performance for the last several years AND/OR list of

extra-curricular activities pursued;

6- Years in which you ran the race or were a Dipsea Race volunteer (please include the

volunteer jobs you performed);

7- Letters of recommendation.

Completed Scholarship Applications must be received by May 1^st.

Please read the qualifications carefully, and if you have questions, contact the scholarship coordinator, Julie Hauke at (415) 898-1130.

SUBMIT COMPLETED APPLICATIONS BY MAY 1 TO:

THE DIPSEA RACE FOUNDATION

Post Office Box 10

Mill Valley, CA 94942