Rector High School SPORTS

HALL OF FAME

SCHOLARSHIP APPLICATION FORM

PERSONAL INFORMATION (Type Please)

NAME___________________________________________________

ADDRESS_______________________________________________

CITY, STATE, ZIP_________________________________________

TELEPHONE_____________________________________________

SOCIAL SEC. NO.________________________________________

MALE / FEMALE_________________________________________

DATE OF BIRTH_________________________________________

FATHER’S NAME________________________________________

FATHER’S OCCUPATION__________________________________

MOTHER’S NAME_______________________________________

MOTHER’S OCCUPATION_________________________________

YOUR HIGH SCHOOL_____________________________________

COUNSELOR___________________________________________

DATES ATTENDED______________________________________

COACHES_____________________________________________

INTENDED OCCUPATION_________________________________

SIGNATURES:

APPLICANT:____________________________________________

PARENT / GUARDIAN_____________________________________

Send Scholarship Application To: Rector High School Sports Hall of Fame, Inc.

C/O Dr. Owen Moseley 1703 Loberg Lane, Jonesboro,  AR 72401-4670

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ACTIVITIES, HONORS, AWARDS, SERVICES

List the extracurricular activities in which you have engaged OTHER then athletics.

List the athletic activities in which you have engaged and honors for ATHLETICS

TO BE COMPLETED BY APPLICANT’S SCHOOL PERSONNEL

1. GPA ___________________ GRADUATION DATE____________________

2. SIGNATURE OF COACH________________________________________

3. SIGNATURE OF PRINCIPAL_____________________________________

4. DATE_____________________ Affix High School Seal