Elyssa's Mission® Scholarship Application
Deadline for submission is March 18th, 2019 at 11:59pm.
Last Name, First Name *
Your answer
Mailing Street Address (Include city, state, 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
Your Grade Level *
First and Last Name of an Adult Reference from 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 help-seeking message (Acknowledge, Care, Tell). Choose only one option below.
Option 1: Narrative (should not exceed 650 words) - Describe the specific way you helped yourself or a friend by using the ACT steps (Acknowledge, Care, Tell).

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).

Option 1 Narrative (650 words or less):
Your answer
Option 2 Artistic Submission
Option 2 Narrative (250 words or less):
Your answer
Please mail your Art Supplement to: Elyssa's Mission Office, 900 Skokie Blvd. Suite 120, Northbrook, IL 60062
For questions or clarification about the scholarship or application, please email Sarah Shaheen, the Elyssa's Mission Scholarship Chair at sshaheen@loy.org.
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