Elyssa's Mission Scholarship Application
Deadline for submission is February 19, 2018
Last name, First name *
Your answer
Mailing Street Address (Include City, State and Zip Code) *
Your answer
Phone Number *
Your answer
Email Address *
Your answer
High School Name *
Your answer
High School Street Address (include City, State, Zip Code) *
Your answer
Grade Level *
First and Last Name of an Adult Reference in your School *
Your answer
Adult Reference Job Title *
Your answer
Adult Reference Email Address *
Your answer
Adult Reference Phone Number *
Your answer
Demonstrated use of the ACT steps (Acknowedge, Care, Tell).
Option1: Narrative (should not exceed 650 words) - Describe the specific way that you helped a friend or yourself by using the ACT steps (Acknowledge, Care , Tell)
Your answer
Option 2: Artistic Submission - Through the use of art, music, poetry etc. please depict how you helped a friend or yourself by using the ACT (Acknowledge, Care, Tell) steps. You must supplement your artistic submission with a brief narrative detailing how the ACT steps are incorporated (should not exceed 250 words).
Artistic Submission Narrative
Your answer
Please mail your supplement to Elyssa's Mission 900 Skokie Blvd. Suite 120 Northbrook IL 60062
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