Elyssa's Mission® Scholarship Application
Deadline for submission is March 23, 2021 at 11:59pm.
Last Name, First Name *
Mailing Street Address (Include city, state, zip code) *
Phone Number *
Email Address *
High School Name *
High School Street Address (Include city, state, zip code) *
Your Grade Level *
First and Last Name of an Adult Reference from your School *
Your school reference may be contacted to confirm any community involvement you may have referenced in your submission
Adult Reference Job Title *
Adult Reference Email Address *
Adult Reference Phone Number *
If your school did not implement the SOS Program this year, how did you hear about Elyssa's Mission, the SOS Program and/or this scholarship?
Demonstrated how you used 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):
Option 2 Artistic Submission
Clear selection
Option 2 Narrative (250 words or less):
Please mail your Art Submissions only to: Elyssa's Mission Office, 900 Skokie Blvd. Suite 120, Northbrook, IL 60062
Clear selection
For questions or clarification about the scholarship or application, please email Palma Lacey, the Elyssa's Mission Scholarship Program Administrator at palmalacey@elyssasmission.org.
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