Application PERSONAL INFORMATION. Gender Ethnicity I am applying to UCLA Are you a US Citizen?

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1 Application PERSONAL INFORMATION I am applying to UCLA Are you a US Citizen? Home Address City County State Zip Date of Birth Home Telephone Number Cell Phone Number Other Phone Number Primary Address Secondary Address Please Upload Your Photo Do you have any disabilities that you would like to share with us? (i.e., physical, vision, hearing, learning) How did you learn about the Jackie Robinson Foundation Scholarship? LANGUAGE Language spoken at home other than English. Please select a second language you speak other than English. If you speak any languages not listed above, please enter them here: ACADEMIC INFORMATION Applicant s Current School Location of High School Name of High School High School Address City State Zip Guidance Counselor s Name Guidance Counselor s My High School is: High School Website The area which best describes my high school is... What is the total number of students enrolled in your high school?

2 If you attend a school that uses a 5.0 grading scale, please make conversions based on an absolute scale of 4.0. School Year School Year School Year School Year Class Rank What is the size of your graduating class? Have you completed any college credits? Have you completed any AP courses? Have you completed any college credits? TRANSCRIPT Submit an official high school transcript that coincides with the course and grade information provided Upload Transcript Submit an official high school transcript that coincides with the grade information provided above. You should upload a PDF of the official paper transcript issued to you by the registrar at your High School. If the transcript is issued to you in a sealed envelope, it is acceptable for you to open it for the purpose of uploading. SCHOLASTIC INFORMATION TEST INFORMATION SAT SCORE: Critical Reading Math ACT SCORE Composite ACT Score Writing Total Score Total Score without Writing COLLEGE INFORMATION Please list the colleges to which you have applied or will apply in order of choice. First Choice Second Choice Third Choice

3 MAJOR/MINOR What is your intended major(s)? What are your intended minor(s)? What are your professional aspirations? Are you a first generation college student? (If either parent/guardian earned at least a four year college degree, answer No) AWARDS/HONORS Please indicate if you are being considered for: Valedictorian Salutatorian National Honor Society List any academic honors you have received in high school. EXTRACURRICULAR ACTIVITIES Activity 1 Activity 2 Activity 3 Activity 4 If you have participated in academic programs outside of your high school, please list name of program, sponsoring institution, participation dates and certification, credits awarded (if applicable.) Have you participated in academic programs outside of your high school? Name of Program Sponsoring Institution Dates Certification Credits Awarded Have you ever traveled domestically outside your state? Have you ever travelled internationally?

4 FINANCIAL INFORMATION SCHOLARSHIPS Gross Annual Family Income How many people currently reside in your home, including you? Is this a single or dual parent household? How many siblings are 23 years of age or younger? Number of siblings currently attending college Were you employed while in high school? (Includes summers) Have you applied for/will apply for any of the following scholarships or mentoring programs from any organization other than those offered by your college or university, including but not limited to: Coca Cola Scholarship Gates Millennium Scholarship Hispanic Scholarship Fund NAACP College Scholarship Point Foundation Posse Foundation Church Scholarship Ron Brown Scholarship ROTC Scholarship State Scholarship Thurgood Marshall Scholarship UNCF Scholarship FAFSA Other Scholarship #1 Other Scholarship #2 Other Scholarship #3 Federal Student Aid, a part of the U.S. Department of Education, is the largest provider of student financial aid in the nation. If you have already filed your Free Application for Federal Student Aid (FAFSA) please upload it below (the preferred method for this document is a PDF file). Upload FAFSA Application HOUSEHOLD 1 (PRIMARY RESIDENCE OF APPLICANT) Are the applicant s parents/guardians divorced, separated or otherwise living separately? Home Address City & County State & Zip Country PARENT 1/GUARDIAN HOUSEHOLD 1 INFORMATION Title Relationship to Applicant Is Parent/Guardian a US Citizen? What is the highest level of education Parent/Guardian 1 has achieved? Telephone Cell Phone Address Occupation

5 PARENT 2/GUARDIAN HOUSEHOLD 1 INFORMATION Title Relationship to Applicant Is Parent/Guardian a US Citizen? What is the highest level of education Parent/Guardian 1 has achieved? Telephone Cell Phone Address Occupation ESSAY QUESTIONS JACKIE ROBINSON Jackie Robinson is best known for the courageous role he played in the integration of Major League Baseball in In fact, Jackie Robinson exhibited courage and humanitarianism on many fronts overcoming unforeseen barriers and challenges which impacted our entire social fabric. What kinds of obstacles have you overcome? What can young people learn and take away from a study of the life of Jackie Robinson? CURRENT EVENTS What do you consider to be the most pressing global issue today and why? LEADERSHIP Jackie Robinson embodied his statement A life is not important except in its impact on other lives. Describe a situation where you took a leadership role, including why you led the project and how you were effective. How have you personally given back to others? PERSONAL ESSAY Write an essay which conveys to the reader a sense of who you are. Possible topics MAY include experiences that have shaped your life, the circumstances of your upbringing, the way you see the world or any personal theme which appeals to your imagination. ELECTRONIC SIGNATURE The electronic signature below and its related fields are treated by the Jackie Robinson Foundation like a physical handwritten signature on a paper form. I certify that the information I have provided in this application is complete and accurate and that all statements and essays are entirely my own work. I understand that my scholarship award may be rescinded should the Jackie Robinson Foundation determine that I have misrepresented or omitted any material information in my application, or should there be any material change in my candidacy subsequent to the submission of my application. I hereby authorize all persons or entities to provide any information that will serve to verify the information I have presented in my application; I expressly waive any required notice to me. I also understand that if I accept a Jackie Robinson Foundation Scholarship, the Foundation or its agent may verify information included in my application. I hereby authorize the Jackie Robinson Foundation to share my application information with scholarship organizations, foundations and other entities concerned with advancing educational opportunities. Electronic Signature Date